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Business Scenario
This scenario features sample tasks performed by a contracting specialist, a provider relations representative, and a member service representative. Your company may follow a different workflow according to its business requirements.
In this scenario, a contracting specialist for a health plan is responsible for managing information about the healthcare providers with which her company does business. She just established a contract with a single provider.
She adds the new provider and then adds information about the provider's area of specialization. Next, she adds information about the provider's primary location (for example, a medical group or pharmacy), affiliations (such as hospitals or health networks), and whether or not hospital affiliations include admitting privileges. After that, she adds information about the provider's skills, background, and clinic locations and hours. Then she adds information about contracts the provider holds with her company and adds the provider's payment preferences.
A provider relations representative provides service for the provider. He uses the:
- Encounters view and the Claims view to refer to reports regarding patient visits and claims
- Payments view to refer to payments made to the provider
- Service Requests view to add service requests such as referral inquiries
- Alerts view to add important notes about this provider
A member service representative uses Siebel eHealthcare to answer questions about contracted providers. Using the Provider Locator, she searches for providers by city, state, or ZIP Code. She views and prints Provider reports based on the product and speciality. Also, she can view some of the information the contracting specialist adds in the Providers screen and the Products screen. For example, the Products screen displays information about providers in the Primary Providers view and the Contracted Providers view.
In this scenario, end users are health plan contracting specialists, provider relations representatives, and member service representatives. They use Siebel eHealthcare to:
- Add a new providers and provider addresses
- Associate a facility with a provider
- Associate a specialty with a provider and add profile information
- Add a provider contract
- View provider payments
- Add a provider claim
- View and print provider reports
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Siebel eHealthcare Guide Published: 04 June 2003 |