11Members
Members
The chapter explains the procedures necessary to administer and use the members functionality in Siebel Healthcare. It includes the following topics:
About Members for Siebel Healthcare
Members are individuals who are insured by an organization. In some cases, members are also known as policyholders, subscribers, or insureds.
The Members screen allows user to manage insurance policy members. It allows end users to add and track information about members with whom they do business, such as enrolling them in health programs; changing a member’s primary care provider, primary network, or independent practice association (IPA); or adding service requests or activities for members.
Scenario for Handling Insurance Agent and Member Inquiries
This scenario features sample tasks performed by a call center representative. Your company mightn’t follow a different workflow according to its business requirements.
In this scenario, a call center representative for a health plan or an insurance company is handling multiple calls each day from insurance agents and members.
Typically, members call to ask questions regarding their insurance coverage. The call center representative accesses this information in the Members screen, Summary view. To enroll members in a health program, she uses the Health Programs view. To handle a request for a change of primary care provider (PCP) or a primary network or independent practice association (IPA), she goes to the Benefits view.
Members often call to request information about providers. After the representative adds provider records in the Providers screen, she can view them in both the Providers and Contacts screens. She can view the member’s current provider in the Members Benefits view. She can also use this view to process requests to change a member’s primary care provider
In this scenario, end users are the call center representatives. They enter information to:
Enroll a member in a health program
Charge a PCP, primary network, or IPA for members
Add additional benefits coverage
Administrator Procedures for Members
The following administrator procedure is described in this section:
Adding Health Programs
Health programs are medical programs designed to maintain a member’s health or to prevent disease. Health programs include those that offer maternity care or infant care, diet and exercise programs, and chronic-illness management programs.
To add a health program
Navigate to Site Map, Administration - Insurance, then Health Programs.
In the Health Programs list, add a record and complete the necessary fields.
Configuring the Command Center for Common Member Services
Siebel Healthcare ships with the Command Center applet embedded in the Member Summary view. In order for the Command Center applet to work as described in Example of Using the Command Center for Common Member Services, the applet needs to be configured as described in Example of Configuring the Command Center Action Applet.
Also provided, is an alternate, preconfigured, common task applet. You can replace the Command Center applet with the common task applet using Siebel Tools.
To configure the common task applet
Log in to Siebel Tools or Web Tools as Administrator and create a new Workspace
In the Object Explorer, select View.
Query for FINS Member Summary View.
Expand the View in the Object Explorer.
Select View Web Template and select the Base template.
Expand the Web Templates within the Object Explorer to expose the View Web Template Item.
Replace the FINS Command Center Action Form Applet with the FINS Member Summary Common Task List Applet.
Deliver the changes to the Integration Branch. For more information, see Using Siebel Tools.
End-User Procedures for Members
The following end-user procedures are described in this section:
Editing the Layout of the Members Summary View
The Members Summary view has an editable layout so end users can arrange the view information to meet their needs.
To edit the Members Summary view layout
Navigate to Members and then the Summary view.
Click Edit Layout.
In the Edit Layout form, make changes by clicking the different controls that appear on each list or form.
For more on edit layout controls, see Siebel Fundamentals.
Click Done to register the changes and return to the Members Summary view.
Enrolling Members in Health Programs
Health Programs are medical programs designed to maintain a member’s health or to prevent disease. Health programs include those that offer maternity care or infant care, diet and exercise programs, and chronic-illness management programs. Once a member is added, they can be enrolled in a health program.
To enroll a member in a health program
Navigate to the Members screen.
In the Members list, drill down on the last name of the member to be enrolled.
Click the Health Programs view tab.
In the Health Programs list, add a record and complete the necessary fields.
Example of Using the Command Center for Common Member Services
The Command Center is a quick launch point for several common member processes. Available on the Members Summary view, end users can use the drop-down menus to perform such member services tasks as:
Order a new ID card
Change the PCP
View claims information
Show a history of ID card orders and changes to PCP
On the Members Summary view, the Command Center is not preconfigured to perform these or any functions. It must be set up to run the member processes particular to your business. This section presents an example of how the Command Center could be used on the Members Summary view. The necessary configuration to set up the Command Center to run the processes shown in this example, appears in Example of Configuring the Command Center Action Applet.
For additional information about the Command Center feature, see About Command Center.
ID Card Requests
When a member requests a new ID card, the call center representative would typically first check for outstanding card requests and then place the new card order. The Command Center on the Members Summary view provides a convenient way to retrieve the order history and then place a new order.
To check the ID card order history
Navigate to the Members screen.
In the Members list, drill down on the last name of the member.
Click the Summary view tab.
In the Command Center form, in the Area field drop-down list, select ID Card Requests.
In the Action field drop-down list, select Show History.
Click Go.
The Order ID History dialog box appears.
Placing a New ID Card Order
Use the following procedure to place a new ID card order.
To place a new ID card order
Navigate to the Members screen.
In the Members list, drill down on the last name of the member.
Click the Summary view tab.
In the Command Center form, in the Area field drop-down list, select ID Card Requests.
In the Action field drop-down list, Order New ID Card.
Click Go.
The application navigates to the Members Benefits view.
In the Benefits list, select the policy for which to order the ID card.
Click Order ID.
Complete the fields in the service request form.
Click Submit to submit the service request for fulfillment.
Note: The fulfillment process can be implemented using Assignment Manager or Siebel business services.
PCP Requests
The Command Center on the Members Summary view provides a convenient way to retrieve primary care provider (PCP) history and update Siebel Healthcare with any changes.
To check the PCP change history
Navigate to the Members screen.
In the Members list, drill down on the last name of the member.
Click the Summary view tab.
In the Command Center form, in the Area field drop-down list, select PCP Requests.
In the Action field drop-down list, select Show History.
Click Go.
The Change PCP History dialog box appears.
Changing the PCP
Use the following procedure to change the PCP.
To change the PCP
Navigate to the Members screen.
In the Members list, drill down on the last name of the member.
Click the Summary view tab.
In the Command Center form, in the Area field drop-down list, select PCP Requests.
In the Action field drop-down list, Change PCP.
Click Go.
The application navigates to the Members Benefits view.
In the Benefits list, select the policy for which to change the PCP.
Click Change PCP.
The Service Member Services and then the Change PCP view appears.
In the Service Request Change PCP view:
Pick a reason code
Select a new PCP
Select a new primary network
(Optional) Use the Provider Locator functionality to select a new PCP:
Click Provider Search button
In the Provider Locator view, enter appropriate search criteria and click Go
In the list of providers returned, drill into the a provider name for more details
On the Provider Details view, click Select this Provider to continue with the Service Request
Alternatively, click Restart Search to perform search again using a new criteria
(Optional) To alert old/new provider and member on PCP change:
Click Email Update
Select the appropriate party to whom you wish to send an email
(Optional) Make modifications to the content
Click Send to send the email
Click Submit to submit the service request for fulfillment.
Note: The fulfillment process can be implemented using Assignment Manager or Siebel business services.
Claims Inquiries
End users can use the Command Center on the Members Summary view to respond to claims inquires and quickly navigate to the Members Claims view.
To view claims information
Navigate to the Members screen.
In the Members list, drill down on the last name of the member.
Click the Summary view tab.
In the Command Center form, in the Area field drop-down list, select Claims Inquiries.
In the Action field drop-down list, select View Claims Info.
Click Go.
The Members Claims view appears.
Changing the Primary Network or IPA for Members
If a member changes primary network or independent practice association (IPA), end users can update Siebel Healthcare to reflect the change.
To make changes to member care information
Navigate to the Members screen.
In the Members list, drill down on the member’s last name.
Click the Benefits view tab.
In the Benefits list, select the Primary Network/IPA field and enter the new information.
Adding Additional Benefits Coverage for Members
Additional benefits are called coordination of benefits. Two examples are:
When the spouse of a member has the same coverage as the member.
When a member has medicare as secondary coverage.
To add an additional benefits coverage
Navigate to the Members screen.
In the Members list, drill down on the member’s last name.
Click the Coordination of Benefits view tab.
In the Coordination of Benefits list, add a record.
In the Add Coordination of Benefits dialog box, perform the appropriate task:
Select a record and click OK.
Click New to add a new record.
Setting the Member HIPAA Privacy Option
United States law requires that medical institutions disclose their privacy policies regarding the sharing of non-public personal information with third parties and fair credit reporting that impacts the sharing of non-public personal information with affiliates. End users can specify a privacy level by making a selection from the HIPAA Option field.
The HIPAA Option field is for registering the privacy level requested by the contact; it does not impact record visibility in any way.
To record a member’s HIPAA privacy choice
Navigate to the Members screen.
In the Members list, drill down on the member’s last name.
In the Members form, specify a HIPAA choice in the HIPAA Option field, selecting one of the following:
Opt-In. Sharing of non-public personal information is allowed without restrictions.
Opt-Out - Affiliates. Sharing of non-public personal information with affiliates is not allowed.
Opt-Out - Third Party. Sharing of non-public personal information with third parties is not allowed.
Opt-Out - All Parties. Sharing of non-public personal information with any affiliate or third party is not allowed.