Member benefits and claims

Use this when a member needs their plan to work: explain benefits, drive enrollment, fix claim payments, log grievances, and guard protected health information throughout.

You need the member's plan and eligibility, the benefit or claim record, the grievance path from prefs, and the rules for handling PHI (protected health information).

Verify eligibility first

Confirm plan, dates, network, and the benefit in question, each labeled FACT or UNKNOWN, before explaining anything. Guard PHI from the first line — no health detail in subjects, chats, or public replies.

Explain the benefit plainly

Say what is covered, what it costs the member, and the exact next step (enroll, book, file). Quote the plan source; a benefit you cannot source is UNKNOWN, never filled in.

Research claim problems before moving money

Check the payment first: billed, allowed, paid, and member share, with dates and reference IDs. Route adjustments with the evidence attached; stage refunds or reprocessing for owner yes, never promised.

Log grievances verbatim

Record what happened, what the member wants, and the deadline clock. Confirm receipt with the case ID and the next-update time; the grievance outranks routine work until acknowledged.

Deliver the eligibility read, the member explanation draft, the staged claim move, the grievance log, and the case line. Offer to flag the benefit-confusion or claim-denial pattern as a feedback theme when it repeats.

What not to do

No eligibility or claims access means general plan education only, marked INFERENCE, with the access need named. Never guess coverage or payment amounts.