Pega Customer Service for Healthcare includes several standard case types. These case types are
available for selection within the New Application wizard when you create your Pega Customer Service for Healthcare application. Depending on your service needs, you might include all, none, or
a subset of these case types in your application. In addition, you can create new case types to
meet your service needs.
Pega Customer Service for Healthcare
Product Overview
Member Services
| Service tasks/requests | Description |
| Add Child Dependents | Enter and process information about new child dependents to be added to a
plan |
| Authorization Inquiry | Respond to customer questions about authorization statuses |
| Claims Inquiry | Respond to claims related questions using information such as claim status,
information about out-of-pocket costs, and service history. The case creates
follow-up work based on the context of the interaction. |
| Coordination of Benefits | Collect policy information when members are covered by multiple plans. This
coordinates benefit coverage and improves claims accuracy. |
| Coverage Inquiry** | Preemptively inform members about potential benefit issues and options |
| Create Lead‡ | Create a sales lead during a customer service interaction and route to a sales
rep. |
| Create Opportunity‡ | Add, view, and modify sales opportunities during a customer service
interaction. |
| Exercise Data Rights | Support customer requests to exercise their GDPR rights by making a request for
data access and follow on requests (if applicable) to rectify, restrict or
remove. |
| Find Provider | Search for provider organizations or individual practitioners based on
criteria, such as plan and location. |
| Log General Service Request | Create an ad hoc case to log a general customer request. |
| Medicare Inquiry | Qualifies inbound inquiries about Medicare plans, using industry-standard
questions. Results include Medicare plans available to the customer. |
| Order ID Card | Request identification cards for members |
| Patient Assistance | Enroll members in Patient Assistance programs that assist them with medical
expenses. |
| Start Co-Browse | Collaborate in real-time with a customer by sharing a browser session and
providing visual guidance on how to navigate a website. |
| Update Contact Profile | Update contact profile information such as first, middle, and last name, date
of birth, and marketing communication preferences. |
| Update PCP | Update member’s primary care provider (PCP). |
| View Benefits | Review the member’s plan and product eligibility information including
information on specific benefit coverage. |
| Welcome Member | Engages and educates new health plan members in self-service channels. It
promotes benefits and programs and captures care team information. |
- ** Requires Pega Customer Decision Hub license
- ‡ Requires Pega Sales Automation license
Provider Services
| Service tasks/requests | Description |
| Appeal a Prior Authorization Denial | Initiate and process the appeal of a previously denied authorization
(pre-certification) request on behalf of the member for whom the service was
requested. |
| Authorization Inquiry | Respond to customer questions about authorization statuses |
| Authorization Intake | Receives and processes authorization requests from providers. |
| Claims Inquiry | Respond to claims related questions using information such as claim status,
information about out-of-pocket costs, and service history. The case creates
follow-up work based on the context of the interaction. |
| Coordination of Benefits | Collect policy information when members are covered by multiple plans. This
coordinates benefit coverage and improves claims accuracy. |
| Log General Service Request | Create an ad hoc case to log a general customer request. |
| Start Co-Browse | Collaborate in real-time with a customer by sharing a browser session and
providing visual guidance on how to navigate a web site. |
| Update Contact Profile | Update contact profile information such as first, middle, and last name, date
of birth, and marketing communication preferences. |
| Update NPI | Update or correct a provider’s NPI number. |
| Update Practitioner Address | Collect updates practitioner’s addresses. |
| Update Hospital Admitting Privileges | Update the list of hospitals at which a practitioner holds admitting
privileges |
| Update Practitioner Business Affiliations | Update a practitioner's relationship with the business entities (hospitals,
clinics etc.) with which they are associated. |
| Update Practitioner Languages | Update the languages spoken by a practitioner. |
| Update Practitioner Licenses | Update the license related information held by a practitioner, such as a
state-issued medical licenses, DEA number, and Medicare and Medicaid
numbers. |
| Update Practitioner Specialties | Update the type of provider and the specialties recorded for the
practitioner. |
| View Benefits | Review the member’s plan and product eligibility information including
information on specific benefit coverage. |
Patient Services
| Service tasks/requests | Description |
| Log General Service Request | Create an ad hoc case to log a general customer request. |
| Manage Medical Appointment | Enables representatives to reschedule or cancel existing medical appointments for
patients while interacting with them or an authorized contact on their behalf. |
| Patient Assistance | Enroll patients in Patient Assistance programs that assist them with medical
expenses. |
| Schedule Medical Appointment | Enables representatives to schedule medical appointments for patients while
interacting with them or an authorized contact on their behalf. |
| Start Co-Browse | Collaborate in real-time with a customer by sharing a browser session and
providing visual guidance on how to navigate a web site. |
| Update Contact Profile | Update contact profile information such as first, middle, and last name, date of
birth, and marketing communication preferences. |
| Reminder Management | Sends reminders to patients for scheduled medical appointments. You can send
reminders by using email, Short Message Service (SMS) texts, and mobile notification.
You can also configure the frequency and interval of the reminders. |
- **Requires Pega Customer Decision Hub license
- ‡Requires Pega Sales Automation for Healthcare license
