Starting from the explanation of benefits (EOB), the current claims experience is frustrating to members. At best, it constitutes a collection of disconnected touchpoints. At worst, it bloats overhead and contributes to member churn.

If a member has a question about how a claim was adjudicated, the only option is to call members services. If that question constitutes an appeal, the member must hunt down, fill out, and submit a form…then wait. In some cases, a week or more can go by before the member even sees an acknowledgement that the appeal form was received. Once received, it can take another week before the inbound form triggers a case review.

This white paper illustrates the problems with the current state, then describes what the desired future state looks like, and provides details on how the Conversation Cloud platform connects the dots from EOB to appeal to redetermination for the member and your Appeals and Grievances team.

Additional takeaways include:

• How to “smartly” connect the EOB to the appeals process
• How to eliminate the claim appeal form altogether
• How to embed robust correspondence capabilities in Salesforce

The benefits of this solution include:

• Deflecting claim-related calls from member services (lower expenses)
• Resolving claim disputes faster and resolving more at Level 1
• Increasing NPS and CX Index scores and reducing member churn

Download the white paper to learn more!