customer process manager™ for healthcare

Customer Process Manager™ for Healthcare

Provider Services User Guide

7.6 Sp1

Copyright 2013 Pegasystems Inc., Cambridge, MA

All rights reserved

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www.pega.com

Document: Customer Process Manager for Healthcare Provider Services User Guide

Software Version: 7.6 SP1 Updated: November 2013

Contents About This Document ....................................................................................... i

Intended Audience ............................................................................................ i

Guide Organization ........................................................................................... i

Documentation Set ........................................................................................... i

Chapter 1: CPMHC Provider Services Overview ............................................1-1

Benefits of Provider Services .......................................................................... 1-1

PegaCALL™ and CPMHC Provider Services ....................................................... 1-3

PegaCHAT and CPMHC Provider Services ......................................................... 1-3

Chapter 2: Getting Started ...........................................................................2-1

Understanding Provider Services Terminology .................................................. 2-1

User Portal Layouts ....................................................................................... 2-2

Understanding Portal Views ........................................................................... 2-3

Understanding Icons and Controls in the User Interface .................................. 2-13

Setting Desktop Preferences ........................................................................ 2-15

Chapter 3: Working with Provider Services ..................................................3-1

Conducting Live Provider Interactions ............................................................. 3-1

Processing Service Requests Post-Interaction ................................................. 3-29

Using Help and Reference Utilities ................................................................. 3-34

Chapter 4: Understanding Provider Services Business Processing ...............4-1

Service Flows and Business Processes ............................................................. 4-4

Create a General Service Request ................................................................... 4-5

Schedule an Activity ...................................................................................... 4-7

Determine Medicare Primacy ........................................................................ 4-10

Log a Complaint or Compliment .................................................................... 4-13

Send Materials / Literature ........................................................................... 4-15

Send Correspondence ................................................................................. 4-18

Process Frequently Asked Questions ............................................................. 4-20

Presenting a Suggested Offer ....................................................................... 4-23

Reject Offer ............................................................................................... 4-25

Update National Provider ID (NPI) ................................................................ 4-27

Update Provider Credentials ......................................................................... 4-29

Updating Provider Address Information ......................................................... 4-33

Review Member Benefits ............................................................................. 4-35

Request Prior-Authorization (Pre-Certification) ............................................... 4-40

Appeal a Prior Authorization Denial ............................................................... 4-44

Dispute a Claim Payment Denial ................................................................... 4-50

Create a Quick Contact ............................................................................... 4-54

Updating Contact Profile ............................................................................. 4-56

Updating Contact Address Information .......................................................... 4-58

Updating Contact Communication Options...................................................... 4-60

Chapter 5: Reporting ....................................................................................5-1

Reporting and Analysis Tools ......................................................................... 5-1

Drilling Down into Report Data ....................................................................... 5-5

Frequently Used Reports ............................................................................... 5-6

Creating Custom Reports ............................................................................. 5-15

Customer Process Manager for Healthcare Provider Services User Guide

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About This Document The document describes how to use Customer Process Manager for Healthcare for Provider Services to guide CSRs in processing customer service inquires and requests from initiation through resolution

Intended Audience This book addresses users who perform any of the following roles:

Customer service representatives (CSRs) responsible for handling customer calls, inbound correspondence, and front-office research and fulfillment tasks.

Contact center supervisors and managers responsible for ensuring service availability and quality.

Marketing personnel responsible for establishing and monitoring cross-sell and retention campaigns executed by the contact center.

Guide Organization This guide contains the following chapters.

Documentation Set In addition to this document, the Provider Services documentation set includes:

Customer Process Manager™ for Healthcare Implementation Guide — describes how to configure and integrate the Customer Process Manager for Healthcare Solution Framework (CPMHC)

PegaCALL™ Configuration and Operations Guide — describes how to configure and operate PegaCALL in your telephony environment. This document can be found on

Chapter 1: Overview Gives a business overview of Provider Services Chapter 2: Getting Started Describes what you need to know to start using

Provider Services. Chapter 3: Working with Provider Services

Describes how to use Provider Services to conduct customer interactions, process service cases, use CTI and Chat capabilities, and perform supervisory and business analyst functions

Chapter 4: Understanding Provider Services Business Processing

Describes the business flows in detail, explaining how you interact with the system and the business processing that occurs automatically

Chapter 5: Reporting Describes how to access, review, and work with reports


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your CPM media. Note: There are several versions of this guide, choose the document that matches your CTI platform.

PegaCHAT™ Implementation Guide — describes how to implement PegaCHAT for customer service via web-based chat.

All sources are available on the PDN — a section of the Pegasystems Support Network located at pdn.pega.com. In addition, configuration details, technical notes and how to articles for using PegaRULES Process Commander can be accessed in the Application Developer Help and on the PDN.


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Chapter 1: CPMHC Provider Services Overview Customer Process Manager™ for Healthcare (CPMHC) Provider Services is a process-oriented contact center application for managing and automating customer service across multiple customer touch points. This book describes how to use Provider Services to guide CSRs in processing customer service inquires and requests from initiation through resolution.

Key features of Provider Services include:

Optimized interaction management capabilities

Smart scripting and guided next-step processing

A browser-based, context-sensitive user interface

“One-and-done” service process automation

Integrated support for telephone, e-mail, and Web-based channels

Intelligent sales and marketing campaign management

Value-based service level management

Quality performance management

Real-time analytics and reporting

Benefits of Provider Services Provider Services helps reduce service costs and improve customer satisfaction through a process-driven approach that helps to resolve customer issues quickly at the point-of-contact. With Provider Services, your company has new capabilities to:

Improve service effectiveness

Increase operational productivity

Increase customer retention and cross-sell revenue

Reduce training time

Ensure an optimal customer service experience

Optimized Interaction Management The Provider Services Interaction Driver helps optimize every customer interaction. Its built-in intelligence automatically queues business processes based on your company policies as well as on anticipated customer requests. As a result, you can act on service requests before your customers even ask — reducing your call-back frequency and increasing first-call resolution rate.


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Smart Scripting and Guided Next-Step Processing With Provider Services, smart scripting and next-step workflow guide you through every customer interaction — reducing training time and ensuring service consistency. Comprehensive dialog management facilities enable you to create dynamic scripts that are personalized for the customer within the context of the interaction.

Context-Sensitive User Interface Provider Services employs an Internet Explorer-based user interface that dynamically presents information when and where you need it. By presenting information that is both relevant to the customer and to the task you are performing, Provider Services gives you the smart way to handle customer interactions. The browser-based interface means that Provider Services is easy to deploy across your organizations. Optionally, your company can integrate Provider Services forms and windows into other application portals.

“One-and-Done” Service Process Automation Through automated best-practice service workflows that are directly integrated with your legacy and back-end systems in real time, you can resolve customer issues quickly — without transferring or calling back customers, and without passing service fulfillment to the back office. The result is more efficient and effective service. Other capabilities, such as automatic correspondence and service request audit trails, minimize manual work and reduce time-consuming work transfer.

Multi-Channel Support Provider Services includes integrated, multi-channel support capabilities for managing telephone, e-mail, and Web-based service interactions. Using PegaCALL for PegaRULES, Provider Services provides robust CTI support including adaptive screen pops, desktop telephony controls, and enhanced call-out facilities. PegaCHAT enables support for live chat interactions with customers over the web. By leveraging the business rules engine architecture, you can re-use your business processes and rules across channels — from the IVR to the Web.

Intelligent Sales and Marketing Campaigns With its intelligent campaign and offer management capabilities, Provider Services helps you deliver the right offer to the right customer at the right time. Integrated campaign setup and tracking capabilities enable you to easily manage your company’s cross-sell, retention, reward, and restitution campaigns.

Value-Based Service Level Management To help you meet important performance objectives, Provider Services provides sophisticated facilities for managing value-based service level agreements (SLA). You can assign and monitor work, ensuring that tasks are completed according to both business priority and customer value.


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Quality Performance Management Provider Services provides comprehensive capabilities for quality review management to evaluate and monitor employee performance against your company’s quality criteria. Dynamic coaching tips improve productivity and reduce training time by delivering real-time advice and instructions to individual employees while they are interacting with customers.

Real-Time Analytics and Reporting Provider Services includes a wide variety of standard reports and graphs, providing real-time information about processes, work, assignments, and historical data for analyzing contact center performance over time. Powerful drill-down analysis capabilities enable you to travel from a summary view of your entire operation down to the details of a single service-request case.

PegaCALL™ and CPMHC Provider Services PegaCALL provides Computer Telephony Integration (CTI) to improve contact center operations. PegaCALL enhances telephone-based customer interactions such as service inquiries, telemarketing, sales, and collection efforts by integrating business process management capabilities with telephony hardware, software, and industry-standard APIs.

Implementing CTI in contact centers typically involves connecting a computer system to an IVR and a telephone switch. The IVR passes information about calls it is servicing to CPMHC and provides critical information if and when the caller decides to speak to a customer service representative (CSR). This information typically includes the caller’s account number as punched into the touch-tone phone and other information about the IVR interaction.

A telephone switch (PBX or ACD) provides CPMHC with information about the call which enables CPMHC to present customer and call details to the CSR in a screen pop as the call arrives.

The connection between the ACD and the PegaCALL application also allows CSRs to issue telephone switch commands from the workflow for controlling the call. Examples of such commands are hanging up on a call, transferring a call, and making the CSR phone ‘not ready’ for calls.

PegaCHAT and CPMHC Provider Services PegaCHAT provides a pre-configured foundation of rules for the integration of CPMHC with third party chat applications.

PegaCHAT enhances CPMHC’s multichannel offerings to provide immediate, on-demand customer service over the Web. CPMHC’s unique portal design supports simultaneous, concurrent interactions, increasing user productivity.

PegaCHAT rules are installed with CPMHC. You must be licensed to use PegaCHAT in your environment.


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Chapter 2: Getting Started This chapter introduces Provider Services and describes the basics of navigation.

Topics included are:

Understanding Basic Terminology

User Portal Layouts

Understanding Portal Views

Interpreting Icons and Controls

Setting User Preferences

Understanding Provider Services Terminology To begin working with Provider Services, it is useful to become familiar with the following application terminology:

Live interaction — a telephone inquiry or a branch walk-in visit from a customer. Provider Services creates an interaction log to record all activities and service items that result from live customer interactions.

Non-live interaction — an e-mail, fax, or mail inquiry from a customer. Provider Services creates an interaction log to record all activities and service items that result from non-live customer interactions.

CTI (Computer Telephony Integration) — capabilities combining data with voice systems to enhance your contact center operations. Using PegaCALL for PegaRULES, Provider Services supports CTI capabilities such as screen pops, desktop telephony controls, and enhanced call routing.

Case (work item or service request) — a unit of work in Provider Services assigns a unique number called a Work ID to each case, whether it is an interaction or a service request, such as an address change.

Workbasket — a centralized, shared pool of cases from which users can select work. Cases available to a user depend on the user's role. When cases are created, Provider Services routes them to named workbaskets to wait for further processing and automatically retrieves them when users request work.

Worklist — a list of case items assigned to a user. Provider Services routes work from workbaskets to users who are most qualified to process that work. Users can also pull new case items directly to their worklist.

Service level— time interval to complete a request. Provider Services assigns a service level to each unit of work within the system. A service level defines one or two intervals known as goals and deadlines. The intervals indicate the expected or targeted turnaround time for the assignment or the expected amount of time to resolve the case.


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User Portal Layouts This section shows the portal layouts that users in different roles see on their home page when they log into Provider Services. It also includes a table of gadgets associated with each of the user portals:

CPMHC_CSR_Portal — customer service representative

NOTE: Old style CPMHC UI and portals – CPMHCCSRPortal & CPMHCManagerPortal and their derivatives - are

no longer supported. CPMHC operators must use the new UI and portals listed above. The CPMHC_MGR Portal

has been deprecated in CPMHC 7.6 SP1. The manager features are available in the CPMHCCSR_Portal as role

based options.

CPMHC Provider Services CSR Portal

CSR Portal Gadgets

Area Gadget/Function

Home/Dashboard Dashboard Graphs

My Work Home/Report Browser Find Reports

Browser (All Reports) Create Standard Reports Shared Reports

Manager Tools (requires Quality Review Management


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Area Gadget/Function

CPMHC:MGR role) Campaign Management Social Media Tools Reassign Work Portal Controls Chat Tools Call Volume Indicator Phone Tools New Work Menu Search Operator Menu

Understanding Portal Views A Provider Services portal has three main views.

Home View

Interaction View

General Work View

Home View The Home view is displayed on log in. In this portal, the user has access to chat and phone controls, processing menus and the search function in the toolbar. Role specific reports display in easy to ready graphical formats. They can select and process items on their personal worklists as well as general and team workbaskets.

The table below briefly describes the tabs and gadgets that are available in the Home view.


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Note: Gadget functions are role-dependent and vary.

Tab/Gadget Description

Header/Toolbar Access to chat and phone icons, process and preference menus, search

Dashboard Role-specific reports and graphs (For more information, see Chapter 5)

My Work Select work from your personal work list , team work baskets, view recent work, and get most urgent work

Report Browser Provides a comprehensive list of reports by category

Manager Tools (not present in all portals)

Click to expose a list or reports and management tools that includes: Quality Review Management — Supervisory functions that enable managers to evaluate and rate the quality of interactions and service items, and to use coaching tips to manage and improve employee performance Campaign Management — Supervisory functions that enable managers to view information and progress of cross-sell, retention, restitution, and reward campaigns Business Analyst Tools – Tools to analyze and measure intent usage and interaction goals

Social Media Tools – Bulk Social Processing tool to analyze and process harvested social media cases

Reassign Work – Tools to reassign work and perform bulk processing on assignments

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Interaction View Customer interactions can be started from the New menu option at the top of the portal. Interactions can also be started from a CTI or chat screen pop based on your site’s integration with channel platforms.

During an interaction, your view will look similar to the screen below.

This table describes the elements that can appear.

Gadget Description

Interaction Thumbnail

Displays customer reference information and dialog scripting for each step of the customer interaction

Interaction Tabs Displays the customer name and interaction timer for each interaction in progress. You can switch between different interactions by clicking on the tab.

Interaction Driver Area to select and perform processes. The contents of the action area change depending on what step a process you


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Gadget Description

are in. Customer Composite Reference area that contains information regarding the

customer, such as transaction history and profile, recent claims and authorizations.

Interaction Navigation Methods Provider Services offers two navigation methods that can be used during a customer interaction.

Note: These navigation methods apply only to work that occurs during an interaction. Navigation and

processing of work post-interaction is not affected.

As shipped, Provider Services allows end users to choose the navigation method they prefer. Users can make this selection using the User Preference control ― see Setting Navigation Preferences in this chapter.

Alternatively, organizations can choose to make this a system-determined function rather than a user selected preference. For example: they want to set the navigation style based on a call queue, or workgroup. This procedure is detailed in the Understanding CPMHC Navigation Options topic in the Customer Process Manager for Healthcare Implementation Guide.

Classic Interaction Navigation Method The classic navigation method is optimized for process and inquiry. This navigation method delivers the most “guided” user experience and the shortest learning time.

Once you verify the customer, you can see the Interaction Driver screen. This screen lets you launch service processes for the customer.


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After selecting a process, the interaction thumbnail and action areas change to walk you through the process and allow you to enter appropriate data.


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Each time you complete a service process, the action area returns to the Interaction Driver so that you may select another process or wrap up the interaction.

The user progresses through one service process at a time and is returned to the Provider Services interaction driver after each service item is either completed or is routed to another user/queue.

Tabbed Interaction Navigation Method This navigation method is optimized for complex processes with layered screens. This method allows multiple service processes to be in-flight at the same time during an interaction.

Clicking the pushpin icon adds a task to the To Do list


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After selecting a process, a new tab opens up for you to enter the appropriate information. A new tab opens for each service process you select.

The Interaction Log of Process Tasks is displayed by clicking the Log link on the right top of the screen.

Clicking the tear off icon displays the composite data tabs in a separate window.


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Confirmation screens can be configured to display additional task suggestions for CSR action for designated processes.


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General Work View Work that must be completed following a customer interaction or other general work can be started by selecting an assignment (task) from the My Work gadget. Additionally, users can also search for customers or work (cases) from the search bar at the top of the portal.

When viewing case information, or when performing post-interaction work, your view will look similar to the screen below.

The table below describes the elements that can appear.

Gadget Description

General tabs Tabs for each customer or work (case) being viewed or worked on.


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Gadget Description

Case area Displays information pertaining to the member and case. If work is being performed, this area will also include the Action area.

When viewing customer data for providers, provider entities, and contacts your view will look similar to the screen shot below.

This table describes the elements that can appear.

Gadget Description

Customer Thumbnail Displays a snapshot of the provider, provider entity, or contact

Composite Tabs Displays information pertaining to the providers, credentials etc.

Recommendations Displays recommended actions and knowledge content based on your site’s business rules (not shown in this example)

Other Actions Displays the menu of processes you can perform for this provider, provider entity, , or contact. Once selected, each process will open in a new tab.


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Understanding Icons and Controls in the User Interface This topic describes the icons and user controls displayed on Provider Services processing screens and illustrates how you interact with these screen elements as you process interactions and service requests.

Common Icons and Controls The following table lists and describes the most common screen icons and controls used to enter or view data, or to take some action when processing work in Provider Services.

Buttons and Icons

Name Description

Action Area – These controls may appear in the action area of your display while performing work

Action button Click to send data on the form to CPM.

Tools Menu Select from the menu to view history, attach notes or

files, check spelling and other available actions

Log View the summary log for the customer interaction

Calendar Click to select dates

Add a row Adds a row to the current list or form Delete a row Click to delete an item from a list; clicking the icon

deletes the item immediately; you are not prompted for confirmation

Help Click to view knowledge content or start expert chat

Configuration Tools

Allows authorized users to configure dialog scripts, coaching tips, knowledge content and expert skills

Interaction Area – These controls may appear in the interaction area while performing customer interactions

Home Icon Returns you to your Home or Dashboard view

Interaction Icon Indicates you are processing a customer interaction. The icon represents the interaction channel

Child Interaction Icon

Indicates you are processing a child interaction

Coaching Tip Hover over the blue “i” to view coaching tips

Interaction Timer Displays interaction duration in comparison to goal and deadline times

Disposition Green Indicates happy or satisfied customer interaction

Disposition Red Indicates unhappy or upset customer interaction

Disposition Yellow Indicates open issues that need to be addressed on an interaction

Priority Note Alerts user that a Priority Note exists on an inquiry


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Buttons and Icons

Name Description

Net Promoter Rating

Displays the customer’s most recent Net Promoter rating. The rating can be used in CPM to drive CSR behaviors – for example, used in determining the interaction goal and service process suggestions

Show Prior Suggestion

Displays the prior suggestions made to a contact during an interaction

Suggestion Indicates a suggested Service Process or offer for the current customer

Composite Area – These controls may appear in the customer composite area while performing customer interactions

Composite Area Bottom

Moves the composite area to the bottom of the workspace while using classic navigation

Composite Area Top

Moves the composite area to the top of the workspace while using classic navigation

Reset Composite Location

Resets the location of the composite area to its starting position while using classic navigation

Reload Composite Area

Refreshes the composite data area during an interaction to provide up-to-date information

Tear Off Composite

Tears off the composite data area from the interaction display and displays it in a separate window

Search Search for cases or transactions

General Work Area – These controls may appear while review or working on cases

History Displays case history and audit trail

Attachments View or add attachments in a pop-up window

Close Closes a tab or workspace

Expand All Expands all currently unexpanded gadgets

Collapse All Collapses all currently expanded sections

View Content Indicates that the current work object is a cover Click

to access the contents (associated cases) of the cover

Where am I? On a worklist, pops-up an information box with basic details about a case; also opens a flow diagram of the current workflow that pinpoints where you are in the process.

General – Additional controls and icons

Expandable Section Indicator

Click the right-facing triangle next to a gadget to expand the section to show previously hidden information; the expanded section then becomes a collapsible section, marked with the triangle pointing down


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Buttons and Icons

Name Description

Service Level Goal Indicates an assignment or work object remains incomplete past its service level goal

Service Level Deadline

Indicates an assignment or work object remains incomplete past its service level deadline

Knowledge Rating Click to rate knowledge content

Chart Indicates the report display contains a chart

Relationship Value Indicator

Represents the customer’s value to the company; value thresholds are maintained in the CARelationshipValue decision table

Setting Desktop Preferences You can select desktop references for your keyboard shortcuts, screen navigation and themes by selecting the Preferences option under your user name with the portal heading.

Setting Keyboard Preferences 1. Click Keyboard to display options for setting Hot Keys. Users with administrative

privileges can also set default Hot Key settings for all users in the system.


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2. Select a task category to display a list of tasks and commands for the category.

3. Click the task/command. It displays next to the entry fields in the Shortcut Key box.

4. Define the key. Click Save Changes. Repeat this process for every shortcut key you want to define.

5. Click Show My Current to display a list of hotkeys that are currently active.


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6. Click Restore System Defaults to delete your custom keys.

Setting Interaction Navigation Preferences Provider Services offers a choice of navigation methods. See Navigation Methods for information about how the choices affect your desktop displays. Depending on your site’s configuration, users may have the ability to select their navigation method.

1. Click Navigation to select your interaction navigation layout preference. This option displays if your organization allows users to choose this preference.

2. Select the layout type – Tabbed or Classic

3. When you select a Tabbed layout, the Auto Tear-Off Composite checkbox appears. Check it if you want to automatically tear off the composite area of the interaction display into a separate window when an interaction is loaded

4. Click Save Changes. Click Cancel to close the display.

Setting Theme Preferences 1. Click Themes to display a list of themes that are available. Select a theme to change

the appearance of your display.


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2. Click Save Changes. You must refresh your browser to use the new theme. Click Cancel to close the display.

Note: As shipped, CPMHC 7.6 SP1 utilizes a new skin rule, CPMSkinTemplate_1, which does not support CPM Themes. Use of CPM Themes requires configuration by your CPMHC Administrator.


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Chapter 3: Working with Provider Services This chapter explains how to navigate the CPMHC user interface to perform the role of a Healthcare Customer Service Representative (CSR). The chapter covers the following topics:

Conducting Live Customer Interactions

Using Phone Tools

Using Chat function

Conducting Non-Live Customer Interactions

Processing Service Requests (Post-Interaction)

Using Help and Reference Utilities

Using Supervisory and Business Analyst Functions

Using Campaign Management Functions

Conducting Live Provider Interactions This section explains how to conduct a live interaction with a provider or caller on behalf of a provider. Responding to a telephone inquiry is an example of a live interaction.

This section covers the following topics:

Identifying and verifying the contact/provider

Searching for a provider

Verifying the provider

Processing service requests

Queuing service processes

Interaction goals

Editing the callback number

Launching service processes

Adding express entries to the interaction history

Performing case reviews and hand-offs

Standard Provider Services business processes

Servicing multiple providers

Accessing contact/ provider information

Ending contact/ provider interactions

Managing interaction handle time

Managing call volumes


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Note: Screens shown in this section use the Classic navigation method. The same processes can be

performed using Tabbed navigation. See Interaction Manager - Navigation Options for descriptions and views

of both methods.

Identifying and Verifying the Contact/Provider A live interaction starts by identifying and verifying the customer. To start the interaction, select Phone Call - Provider from the New menu located on the portal header.

Note: The Provider search is available if your company uses the Provider Services solution.

Note: Your company may use PegaCALLTM for PegaRULES to provide CTI capabilities for your CPMHC

application. If it does, you may be notified of an incoming call via a screen pop. Depending on the information

about the caller that your company’s interactive voice response (IVR) system captures, you may not need to

perform search or verification processes. Refer to Using CTI Functions in this chapter for more information on

CTI integration.

Search for a Provider The interaction thumbnail and action areas change when you begin a provider search. CPMHC requires you to select a contact during a live interaction.

Enter your search criteria and press “Enter” to initiate the search and display the results. Results will appear below the search fields. This example shows results based on a search


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for Provider ID of GEN1. Select the correct contact and click Submit. Click Clear to clear the results and start a new search.

Choose a provider from the search results lists. Select the Is Contact the Selected Provider box. If the contact is not the selected provider, leave the box unchecked and click Submit. A list of approved contacts is displayed.

Verifying the Provider After you make your selection, the action changes to Provider Verified and displays the caller verification information. Verification data is based on provider information defined by your company’s business rules.

Verify the caller by asking a question that is displayed. Once the caller provides the verification information, select the radio button next to the verification data and click Submit to continue. If you cannot verify the provider, select the Provider Not Verified action option.


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Processing Service Requests Once you verify the caller, your view changes to display provider information and options for processing the caller’s service request.

Queuing Service Processes The Select Action area now displays options that let you select the business processes necessary to respond to the caller’s service requests.

The Select Action area contains the following sections:

Other Processes

Suggested Processes


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Suggested Processes —list the processes that Provider Services has determined you may want to be use during this interaction. The basis of the list is information on the caller, account profiles, and recent history. The suggestions are based on your company’s business rules. To select a suggested process, click the check box next to the process name. The process is added to the Queued Processes section to the right of the screen. The following icons may appear next to suggested processes:

Clock - to help you understand the reason why the process is being suggested (e.g. SLA running on an open case)

Light bulb – click to display suggestions previously made to the contact during an interaction (displayed in Classic Navigation only)

Queued Processes —list of processes queued for this interaction. In some cases, the system may automatically queue business processes required during the interaction. For example, in the preceding screen, CPMHC has automatically queued two business processes, a suggested cross-sell offer workflow for Web Self Service Promotion, and Wrap Up (end interaction business process).

Take Action Button — selection of a business processes from categorized lists (see Standard Provider Services Business Processes for a list of processes available with CPMHC). Selected processes can either be launched immediately or added to the list of queued actions. You can also double-click to automatically start the process.

Interaction Goals CPMHC may display an interaction goal in the dialog area during a customer interaction. This goal reflects your company’s business rules and can be based on prior customer interactions, recent customer NPS® rating, customer profile, or other information. CPMHC may use this goal to present different dialog scripts to you for the customer or may use it to present suggested processes.

Editing the Callback Number The Callback Number reflects the caller’s phone number received from the ACD. When PegaCALL™ is installed with CPMHC you can click on the number to trigger an outbound call to the customer in the event the CSR is accidentally disconnected during the interaction.


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Clicking the Edit

link displays a window to allow the CSR to add or change the Callback # to reflect the preferred phone number provided by the customer.

Launching Service Processes To directly launch a service process from the Suggestions or To-Do area, double-click that process.

To launch other actions, click the Take Action button. Select the appropriate action and click Launch or simply double-click on the action. To add the action to the To Do list instead, select the action and click To Do.

To remove an action from the To-Do list, click the icon to the right of the business process name.

Note: The Delete icons do not appear next to business processes that are required for the interaction.

The Take Action panel provides a task search capability allowing you to search for tasks by name.


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Your organization may have also configured some express links that allow CSRs to launch selected processes directly from links on the customer composite.

Executing Processes After you launch a business process, the action and interaction thumbnail areas change to display the information and processing options appropriate for that business process. In some cases, the system may present one or more screens to guide you through entry and selection and to confirm the data before submitting it to the database.

For example, the Update Address business process first prompts you to enter the update and the address information.


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When the change is entered and submitted, the process prompts you to confirm the change before applying it to the provider’s record.

Note: If this icon appears in the dialog section, it indicates that the dialog contains a coaching tip for

the CSR. See Coaching Tips for more information.

When you complete the business process, the Select Action screen displays the process selection and queue options again. Continue to launch business processes until the interaction is complete.

Adding Express Entries to the Interaction History Your organization may have configured the ability to add express entries to the interaction history from the customer composite. These express entries allow CSRs to quickly add a standardized message to the interaction history in order to record simple actions, such as reviewing a customer’s remaining deductible balance. Express entries are shown by a pencil

icon: .

Performing Case Reviews and Handoffs When a case is queued for post-processing review and selected, the Conduct Review action displays. An information section displays at the top of the screen that allows the reviewer to see the details of the case prior to starting the review.

The reviewer use the appropriate action from the Take Action area to continue processing the case from the review step allowing an easy handoff of work started in one channel to be continued in another.


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Standard Business Processes The following table lists the standard business processes available from the Business Process menu. Based on your company’s implementation, additional or alternate business processes may be available. Check with your system administrator to find out which business processes are available on your system.

For more detail about these and other non-standard business processes, see Chapter 4: Understanding Provider Services Business Processing.

Category / Process Description Category: Search Functions Search for a Provider Search for a practitioner Search for a Provider Entity Search for a provider entity (medical group, facility,

hospital etc.) Search for a Work Item Search for prior work item (case) Create Quick Contact Add a new contact record to associate a caller calling

on behalf of the provider / provider entity Category: Contact Update Contact Address Update contact address information Update Contact Communications Options

Update contact communication options

Update Contact Name and Profile Change the contact’s name, and edit the personal profile

Category: General Create General Service Request Create a general service item. Use this process to

capture and route work when an automated workflow has not been created

Schedule Activity Schedule a follow-up call, task, or appointment during an interaction

Determine Medicare Primacy (sample diagnostic process)

Determine Medicare Primacy based on defined business rules

Log a Complaint/Compliment Record a complaint or compliment during an interaction

Send Materials / Literature Order materials (such as product collateral or company information) to be sent to a customer

Send Correspondence Generate an e-mail, fax, or mail document to a customer, based on available templates

Process FAQ Browse an search for you company’s knowledge based topics

Suggested Offers Select and present cross-sell and other offers to a contact.

Category: Provider / Provider Entity Update National Provider ID Update provider’s national provider ID (NPI) Update Credentials Initiate a provider’s credentialing information update

request (only for providers)


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Category / Process Description Update Provider Address Update provider’s address information Review Member Benefits Search for and review a member’s plan benefit

information Request Prior-authorization Submit a prior authorization (pre-certification) service

request Appeal a Prior Auth Denial Initiate an appeal request for a denied prior

authorization (or pre-certification) request Dispute Claim Payment / Denial Initiate a dispute process for a claim

Servicing Multiple Providers CPMHC provides the ability to support multiple providers affiliated with the provider entity during the same interaction. During the interaction with a contact associated with a Provider Entity, the Provider Entity tab of the composite provides a listing of all providers affiliated with the entity. To switch the focus between providers, double click on the desired provider listing. The system prompts for a confirmation, and if confirmed, refreshes the Practioner, Credentialing, and Claims and Authorization tabs with information related to the newly selected provider.

Accessing Provider Information The customer composite area consists of individual tabs that display information about the provider entity practitioner, credentials, and claims and authorizations. Depending on your search criteria, some of these sections do not appear. For example, the Provider Entity tab is visible for interactions with a contact on behalf of a Provider Entity.


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Use the controls at the top right of the composite area to reposition the composite area (including all individual sections) within the workspace.

The following controls are available in both classic and tabbed navigation:

Click to refresh the composite data area to provide up-to-date information.

Click to ‘tear off’ the composite into its own window. This can be useful if the CSR has two monitors and allows more UI room in classic navigation for business processing

The following controls are available in classic navigation only.

Click to move the composite area to the top of the workspace

Click to move the composite area to the bottom of the workspace

Click to return the composite area to its original position

Information in the customer composite areas may have been collected from your legacy processing systems, from the Provider Services database, or from other third-party applications and databases.

Customer Composite


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Provider Entity Tab The Provider Entity tab displays when provider entity is selected during the search process.

This table describes the sections in the Provider Entity tab.

Section Description General Information Displays information such as facility name, tax ID,

NPI, specialty Caller (Contact) Information Caller’s name, role, phone, and email Address Lists all the addresses associated with the provider

entity Participating Providers List of practitioners participating with the provider

entity. Can be used to switch between providers. Recent Interactions & Open Service Items

Displays recent interactions and open service items for this provider entity. Click on any item to view additional details. The icon to the left of interactions provides feedback on the satisfaction of the caller (green is favorable; red is unfavorable, etc.). A clock icon to the left of an open service item indicates whether the case is past its goal or deadline date. Use the search buttons to search for other interactions or service items related to this policy by type and status.


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Practitioner Tab The Practitioner tab displays information about the provider you selected during search processing. This information enables you to respond to provider inquiries about general profiles; credentialing, prior claims, authorization requests, interactions and service items.

This table describes the sections in the Practitioner tab.

Section Description General Information Displays general information about the provider such

as name, NPI, tax ID, license number. Address / Phone / Email Displays all the addresses on file for this provider

including street address for the business, telephone numbers, and email addresses

Recent Interactions and Open Service Items

Displays recent interactions and open service items for this provider. Click on any item to view additional details. The icon to the left of interactions provides feedback on the satisfaction of the caller (green is favorable; red is unfavorable, etc.). A clock icon to the left of an open service item indicates whether the case is past its goal or deadline date. Use the search buttons to search for other interactions or service items related to this policy by type and status.


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Credentials Tab The Credentials tab displays information the provider’s credentials. It enables you to view information about certifications, networks, covering physicians and addresses.

This table describes the sections in the Credentials tab.

Section Description

General Information Displays general credentials for the provider including various IDs, primary specialty, License, and DEA numbers

Certifications Displays specialties associated with the provider and whether or not the provider is Board Certified in a given specialty

Networks Displays all the networks that the provider participates in

Covering Physicians Displays a list of covering physicians associated with the provider


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Claims & Authorizations Tab The tab displays a list of recent claims and authorization requests associated with the provider. Hover over the first column of the listing to see additional details related to the claim or authorization request.

This table lists and describes the sections in the Claims tab.

Section Description Claims Displays a list of most recent claims for the provider

where the provider is either the billing or the service provider.

Authorization Requests Displays a list of most recent authorization requests associated with the provider.

Ending the Interaction The last business process in every live interaction is the Wrap Up. This business process is automatically queued by the system. To launch this business process, select Wrap Up from the right side of the select intent screen and click Start Process, or double-click Wrap Up in the queue list.

The system automatically evaluates and displays information about the primary reason for the interaction and whether the interaction is related to a prior service inquiry. If this information is not accurate, you can override it. You can also answer the net promoter question, and add customer comments regarding the interaction.

If the Net Promoter Framework is installed, NPS Survey follow-up cases are automatically created and routed to a follow up workbasket to allow follow-up with customers to help build a better relationship with the customer.


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If you want to review any of the service items you created prior to ending the interaction, select items from the Interaction Log by clicking Log on the Select Action bar. A separate pop-up window displays information regarding the service item.

Click Submit on the Finalize the Interaction action to complete the interaction and close the interaction tab.

Managing Interaction Handle Time Provider Services displays an interaction timer on each Interaction tab to indicate how the interaction is proceeding in relation to defined service levels.

The left side number is the current interaction time in minutes:seconds.


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The right side number is the interaction time goal.

The icon on the left is colored to indicate where the time is in relation to defined service level goals and deadlines.

The timer stays green when the interaction is within goal and until the Goal time is reached.

When the Goal Time is reached, the clock turns yellow until the Deadline is reached.

When the Deadline time is reached, the clock turns Red.

See Configuring the Interaction Timer in the Customer Process Manager for Healthcare Implementation Guide for information about how to set the interaction service levels.

Managing Call Volumes CPM displays a call volume indicator on the portal header to help monitor and manage the volume of calls your contact center is receiving.

Clicking the volume alert on the portal displays current volume details.


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Using Phone Tools If your company uses PegaCALL for PegaRULES to provide CTI capabilities for your Provider Services application, you can make and transfer calls and conduct conference calls directly from the application. Additionally, it automatically prompts you when incoming calls are transferred to you.

This section covers the following CTI topics:

Logging in/out and setting availability

Screen Pops

Phone Controls

Making a Call

Transferring a Call and Related Interaction

Receiving a Transferred Call with the Related Information

Logging In/Out and Setting Availability You must log into CPMHC’s phone tool bar before you can receive incoming calls or use telephony functions.

Note: This login procedure is separate from logging into the Provider Services application.

1. Select the Phone option from the operator menu to display the phone toolbar in the header of your portal.


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2. Select the phone icon to access the login screen.

3. Enter your Extension, Agent ID and Password. You may also enter a Queue, and Work Mode in some environments. Contact your system administrator to determine which of these elements are appropriate for your telephony environment.

4. Click Login. The system confirms your login and sets your agent status based on your login selections. Once your agent status is set to Available, incoming calls can be routed or transferred to you. You can also make calls.

5. To log out, click the icon and select the Logout option.

Screen Pops A screen pop announces the arrival of an incoming call. Screen pops occur in a separate window and the content varies depending on what information is available about the caller.


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Starting an interaction Click Accept in the screen pop window. The system begins a telephone interaction to log activities during the call. In some configurations, the system may automatically start an interaction without a screen pop.

Depending on the information known about the caller and the activities the customer performed within your company’s IVR system, CPMHC may bypass search and verification processes. For example: if the customer entered verification data in the IVR, CPMHC bypasses additional verification processes.

Declining a Call Click Decline.

The screen pop window closes.

Phone Controls When you make or take a call, the telephony controls change to provide you with flexibility in call handling. The CTI toolbar provides the following controls:

Display Behavior

Select the phone icon to login to CTI

Set the state to ‘Available’ for incoming calls. You may use the sub-menu to also set the work mode to “Auto-In” or “Manual-In”.

Sets the state to ‘After Call Work’

Sets the state to ‘Not Available’ and passes the selected reason to the ACD

Click to logout.

Inactive Line

(Blinking Red) Alerting call on line. Click the line to answer.

Active call on line. Click the line button to place on hold.

Call on hold. Click the line button to retrieve from hold.

Call being placed.


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Enter a phone number to dial, or click the arrow to dial using the dial pad. The dial pad closes when you make a selection from the call action drop down menu.

Call action drop down. This drop down changes based on the state of the lines. The following options are conditionally available:

Call

Hang up

Initiate Consultation Call*

Initiate Conference Call*

Complete Conference Call*

Drop selected party from call

Transfer Call (Blind or single-step transfer)*

Initiate and Complete Transfer (Warm or two-step)*

Send Dial Tone Multi-Frequency (DTMF) tones

*These options are used in conjunction with the ‘Phone #’ text area, and are context sensitive (displayed options depend upon the states of the calls/lines).

Making a Call 1. .Enter the phone number you want to dial in the Enter Phone # input box, or select

the arrow to enter a number using the dial pad.

2. Click Call to initiate the call.

Transferring a Call Provider Services provides the ability to transfer a phone call and the related interaction or service cases by selecting the transfer option from the Tools menu on the Action bar. The transfer option is only available when the CSR is on an active call.


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When clicked, a transfer dialog displays In the destination field, type in the telephone number or extension of the party you wish to transfer the call to. Select one of the transfer modes - Warm or Blind (further described below). Select the interaction you wish to transfer with the call. Then click on the button to transfer the call.

Selecting the Warm transfer mode initiates a two-step process. The caller is put on hold, and you are connected to the 3rd party (using a separate phone line) when you click the Initiate Transfer button. You may speak to the other party and then click on Complete Transfer. The caller and the third party are connected and you are no longer on a call..

Warm transfer mode allows you to ensure that the third party is able to handle the call before completing the transfer. The other party sees a screen pop when the initial “consult” call occurs, but will not be able to select the Accept button on the screen pop until you have completed the transfer.

Selecting the Blind transfer mode immediately transfers the caller to the third party and disconnects you from the call. The other party receives a screen pop including caller and transfer details.

Receiving a Transferred Call with the Related Interaction When another CSR transfers a call to you, he or she may transfer the related interaction with the call. Typically, you will see a screen pop window that includes the reason for the transfer and may include additional information related to the caller or case.

If the transfer is a Warm transfer, you will be able to speak to the other CSR before speaking to the caller. At this time you will see the screen pop window, but the Accept button is not enabled. When the other CSR completes the transfer, you will be connected to the caller and the Accept button is enabled.

In some environments, you may not receive a screen pop. Instead you may see a review screen during the “consult” call (for Warm transfers only). The interaction will automatically


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be opened on your screen when the call transfer is complete, allowing you to continue processing.

You will receive the interaction in the same state in which the other CSR was processing it. If one or more service processes were in progress as part of the interaction, you will receive the service processes as well.

Using Chat Functions If your company uses PegaCHAT to provide online chat capabilities for your Provider Services application, users can receive inbound chat interactions from customers over the web.

This section covers the following chat topics:

1. Logging in/out and setting availability

2. Screen pops

3. Chat controls

Logging In/Out and Setting Availability You must log into the chat facilities before you can receive incoming chats or use chat functions.

Note: This login procedure is separate from logging into the application.

1. Select the Channels option from your operator menu to display the toolbar in the header of your portal..

2. Select the chat icon to access the login screen.


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3. Enter your Chat ID and Password and a Display Name that customers will see during your chat sessions. You must also select a Chat Server and Queue. The work queue determines the types of chats you will receive. Contact your system administrator to determine the values that are appropriate for you.

4. Click Login. The system confirms your login and sets your agent status as Available to receive inbound chats.

5. To log out, click the icon and select the Logout option.

Screen Pops A screen pop announces the arrival of an incoming chat. Screen pops occur in a separate window and the content varies depending on what information is available about the inbound chat.

To start an interaction Click Accept.

The system automatically begins a chat interaction to log activities during the interaction. See the Live Interactions section of this chapter.

Depending on the information known about the inbound requester and the activities the customer performed within your company’s web pages, Provider Services may bypass search and verification processes.

For example: if the customer was signed in and authenticated on your company’s web portal, it may bypass additional verification processes.

To Decline a Chat Click Decline.


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The screen pop window closes. In some configurations, the chat may be rerouted to another available CSR.

Chat Controls The Channels toolbar provides the following display features.

Display Behavior Select the chat icon to login to the chat server

Set the agent state to ‘Available’ for incoming chats or select a queue name to change work queue.

Sets the agent state to ‘Not Available’ for inbound chat requests

Logout of the chat server

Conducting Non-Live Customer Interactions This section describes how to conduct a non-live interaction with a provider to respond to an e-mail, fax, or correspondence inquiry.

This section covers the following topics:

Creating non-live interaction cases

Selecting a non-live interaction case

Identifying the provider and processing service requests

Completing non-live provider interactions

Creating Non-Live Customer Interaction Cases

Automatic Case Creation Provider Services automatically creates non-live interaction cases for inbound e-mail, fax, or correspondence inquiries depending on how your system is implemented. In a typical implementation, Provider Services will:

Listen for inbound e-mails and faxes that arrive at designated folders and automatically create inbound interaction cases. It routes these cases to the Inbound Correspondence workbasket.

Automatically create cases for inbound mail correspondence through integration with your company’s imaging system. It routes these cases to the Inbound Correspondence workbasket.

Automatically created NPS cases to allow follow-up with customers to help build a better relationship with the customer. It routes these cases to the NPSSurveyFollowup workbasket.


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Manual Case Creation You can also manually create non-live interaction cases for inbound e-mail, fax, or correspondence inquiries.

1. Select the Inbound Correspondence option from the New menu on the portal toolbar.

2. Complete the information on the entry form. Select a value from the Channel Type box (email, fax, mail, or other).


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3. To include a new scanned correspondence, select Scan Document. Replace the current image by scanning a new image by clicking Replace Current. The system initiates your local scanning software. Use the icons along the bottom of the input box to manipulate the image. Optionally, you can select Attach a File to attach a file from your PC or other available source.

4. Click Create Case. The system displays a confirmation that includes the case reference number and routes the case to the Inbound Correspondence workbasket.

Selecting a Non-Live Interaction Case To work on a non-live interaction case, select it from the Inbound Correspondence Workbasket. See My Work.

You may also receive a non-live interaction case to work on, resulting from a search or Get Most Urgent operation.

Identifying the Customer and Processing Service Requests The customer associated with a piece of incoming correspondence can be identified when creating the new correspondence case or after the case has been created. If the customer was not identified during case creation, opening the case will display the customer search screen., as shown below..


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After you select the contact, provider, and/or provider entity, your system view changes to include the Provider tab as described in the Live Interaction section of this chapter. Unlike live customer interactions, no verification step is necessary.

To respond to the provider’s inquiry, select the appropriate business process from the Select Action area. See Processing Service Requests Post Interaction.

You can create service items to respond to this inquiry as well as send correspondence to the provider confirming the inquiry. Note that unlike live interactions, no dialog scripting is provided.

To view attachments associated with the inquiry, such as attachments sent by a customer with an e-mail inquiry, click the attachment name. A separate window opens displaying the attachment contents.

Note: Your PC must have the necessary software installed to display the attachment. For example, if a

customer included an MS Word attachment with their e-mail inquiry, you must have a copy of MS Word in order

to display the document.


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Completing Non-Live Interactions Like live interactions, the last process in every non-live interaction is Wrap Up. The system automatically queues this process. To launch the process, click its name in the To Do list.

As with live interactions, the system automatically determines and displays the primary reason for the interaction and the relationship of the interaction to the prior service inquiry. If this information is not correct, you can change it.

If you want to review any of the service items you created prior to ending the interaction, you can select them from the Interaction Log section of the Interaction Manager panel on the left portion of the screen. A separate pop-up window displays information regarding the service item.

Click Submit to complete the interaction.

Processing Service Requests Post-Interaction As a result of provider interactions, service cases are created that may require follow-up work or verification once the interaction is concluded. This section describes how you can find, research, and update service requests.

Finding Service Cases You can access cases in the following ways:

Review assignments on your worklist, the worklists of other CSRs, or system workbaskets – My Work

Review recent work – My Work

Enter search criteria – Portal search

My Work The My Work section of the Portal lets you review open assignments on your personal worklist, review Provider Services workbaskets, or view the worklists of other CSRs. It also lets you review your recent work, whether it has been completed or remains open.

My Work contains several tabs:

To view a list of you current assignments, select the Work List tab. Assignments are sorted by urgency.

To view a list of your recent work, select the Recent Work tab. This list will display work that has been completed and that remains open (even if it is assigned to another user or work basket).

To view a list of system workbaskets, select the Work Basket tab. Select a workbasket from the drop down list.

To view the worklist of other CSRs, select the Team tab, and select their operator ID from the drop down lists.


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1. Click the row corresponding to an assignment you want to work on. The case opens in the General Work tab in a format based on its current status.

2. Alternatively, use the Find Most Urgent button to get and start the next most urgent assignment that is appropriate for your role and skills.

Portal Search You can also use the portal search bar at the top of the Provider Services portal to search for cases. Enter your search criteria or text in the portal search bar and press Enter.

When you select an entry from the results list, the case opens in the General Work tab in a format based on its current status.

Researching and Completing Service Request Cases This topic includes:

Reviewing a Specific Case Summary

Tracking Service Items across Multiple Interactions


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Reviewing Case History

Adding Notes and Attachments

Review a Case Summary 1. Select a case to review by selecting it from a worklist, using portal search facilities,

or selecting it from a customer composite gadget.

2. A separate window opens, displaying information about the item. The data contained in each display varies by the type of the item.

3. The following example is a summary of a correspondence service case. You can see details about the correspondence, the attachment, the customer and contact who processed the case.

Reviewing Case History Click the View history icon on the upper-right portion of the case summary form. A separate window opens, displaying the history of the case.


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A separate window opens that displays the history of the case.

Adding a Note or an Attachment to a Work Case 1. From the Tools menu, select the Add or Edit Attachments. The Attachment window

displays.

2. Click Add and select the type of attachment you want to add.

3. Enter the data into the attachment form.

4. Click OK.


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Researching Customer Information Use the portal search function to research a contact or provider without creating an interaction log for the activity. Enter your search text and press Enter to see a results list.

Select a result to display it in on a tab in the Work area of your portal.

You can view customer history and recent transactions. You can also initiate additional service cases for this customer by selecting a Recommendation if displayed or choosing a process from the Other Actions menu.


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Using Help and Reference Utilities Reference utilities give you access to your company’s reference information and is accessed from the Reference menu on the portal header.

Reference Materials

Provider Finder

Reference Materials Reference Materials gives you access to an online library of product, service, and policy documentation and other informational resources which you may want to consult during an interaction.

This feature also allows you rate materials and view the current rating of the content.

1. Select the Reference Materials option from the Reference menu at the top of the portal. A separate window opens where you can browse and search for knowledge content.

2. Enter a Keyword or browse by category. Click Search.

3. Results display below the search fields. Hover over a rating to display a rating summary. Click the on the display to rate the material.


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4. Select the View Content link to display the material.

Provider Finder The Provider Finder displays the reference implementation of a generic Provider Lookup facility.

1. Select the Provider Finder option from the Reference menu at the top of the portal. A separate window opens where you can search for a provider.

2. Select desired Primary or Alternate Lookup parameters..

3. Click Search. Results display directly below the search values.

4. Click View Google Maps button to view the results plotted on Google Maps.


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Knowledge Help Knowledge help provides users with access to knowledge topics that are recommended for a type of interaction or service process they are currently performing. This is similar to the reference material but filtered for a specific type of work or process.

1. Click on the Action bar during an interaction to display the knowledge repository.

2. Select the >> next to the category to view a short summary of the content.

3. To suggest changes to the content, click Suggest Changes, enter your suggestion and click Submit.

4. Hover over a rating to display a rating summary. Click the control to rate the material.

5. Select the Browse/Search Topics tab to search for additional materials.

Using Supervisory and Business Analyst Functions This section describes functions and capabilities available to supervisors, managers and business analysts. It covers the following topics:

Using the CPM Configuration Tools Gadget

Updating Dialog Scripts

Creating and Assigning Coaching Tips

Associating Knowledge Topics with Screens

Assigning Expert Skill Levels

Reassigning work

Conducting Quality Reviews

Reviewing Customer Satisfaction Surveys

Conducting NPS Follow Up Surveys


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Note: Your role and access group must grant you authority to perform these functions.

Using the CPM Configuration Tools Gadget The CPM Configuration Tools gadget lets authorized business analysts and supervisors perform these functions from an interaction or service item processing screen.

Updating dialog scripts

Creating and assigning coaching tips

Associating knowledge topics with screens

Assigning Expert Skill Levels

Reassigning work

The gadget is launched when you click the icon whenever it appears on an interaction or service item process screen. A pop-up window displays where you can select which of the four functions you want to perform.


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Updating Dialog Scripts The Dialog tab displays suggested wording to use during the customer interaction. Dialog text changes to match the specific business process related to the interaction.

Note: The Dialog tab options that display will differ depending on whether or not there is currently a dialog

script associated with the action.

1. From the CPM Configuration Tools window, select the Dialog tab. The tool displays the current dialog script for the process that is in focus. This is an example of the display when there is an existing dialog script.


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2. If there is no dialog associated with this action, select Create Dialog. A window will appear that will enable you to specify a RuleSet for your new dialog, or reuse an existing dialog. A dialog name will be suggested automatically, based upon the process and action name. Click Create to edit the dialog text.

3. If there is already dialog associated with this action, it will give you the option to update the existing dialog text.

4. Update the existing text or add additional dialog text.

5. Append a reference to customer information within the script by selecting a data source and selecting a field from the data source. Click Append to insert the tag into the text.

6. Select a When value to associate the text with a CSR skill level.

7. Click Save to save changes to the current dialog version.

8. Click Save As to create a new dialog version.

9. Click to display the rules that are related to the dialog script.

Creating and Assigning Coaching Tips Coaching tips help improve employee performance and reinforce best practices. Users with the appropriate privilege can create coaching tips for any screen that is available in a customer interaction. Once created, you can assign the coaching tip to a user or to a workgroup.

Provider Services presents the tips appropriate for the user and the current process assignment.


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To create and assign a coaching tip Coaching tips can be created and assigned using the CPM Configuration Tool. This function allows you to:

Create or modify coaching tips

Assign coaching tips to individual employees or work groups

1. Select the Coaching Tips tab.

2. Enter a Name and Description for the tip and enter the tip Text.

3. Click to add another tip. Click to delete a tip.

4. Click Save. Alternatively, click SaveAs to save it to another RuleSet.

To assign coaching tips 1. In the lower section of the screen, select the tips you want to assign.

2. Click to assign another tip. Click to delete a tip.

3. Select the Assign Type, User or WorkGroup and enter a date range for the tip to be displayed.

4. If you select User, select the operator to receive the online tip.

5. If you select Work Group, select the work group to receive the online tip.


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6. Add a Start and End Date for the tip.


Associating Knowledge Topics with Screens Provider Services allows you to select predefined knowledge topics for reference from processing screens. This provides the CSR with recommendations for content to improve their productivity and reduce the need to search for content.

1. From the CPM Configuration Tools window, select the Knowledge tab. This displays the knowledge topics that will be recommended to the CSR for this current process action.

2. Select a Topic. The Category value and View Content link for the topic are automatically added.

Click to add another topic. Click to delete.

3. Optionally, in the Keywords field, enter a search keyword. CPM will automatically search for topics with this keyword when presenting recommended content on this process action.



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Assigning Expert Skill Levels You can assign expert skill levels to individual processing actions.

1. From the CPM Configuration Tools window, select the Expert Skills tab. This displays the expert skills defined for the current service process

2. Select a Skill Name and enter a Skill Level for the name.

3. Click to add another skill. Click to delete.

4. Click Save Skills.

Reassigning Work Use the Reassign Work section located on the Manager Tools tab of your Home view to perform the following tasks:

Reassign work items from one CSR to another

Reassign work items from one workbasket to another

Perform actions on behalf of a selected CSR

Perform actions on a selected item class on behalf of a selected workbasket


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Only authorized users (managers and supervisors) can reassign work. This gadget does not appear in your portal view if you are not an authorized user.

Conducting Quality Reviews Provider Services enables authorized users to evaluate and rate the quality of interactions and service items for the purpose of managing and improving employee performance.

Selecting Work to Review: 1. From the Manager Tools tab, click Select Work for Quality Review.

2. Select the Sample type – Random or Manual Section. If you select Random, enter the number of review cases you want to display. Click Next >>.

3. Enter the selection criteria for the work you want to review and click Next >>.


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4. If you select a random sample, the system generates cases (up to the number you

specified) that match the criteria you entered.

If you choose a manual sample, the system presents you with a list of up to 50 work items that match your criteria


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5. Check the box next to the work items to be reviewed and click Next >>. Your site’s rules determine the routing of the review. The default routing is the Quality Review workbasket.

Entering Quality Ratings 1. Select the quality review item from the Quality Review workbasket. A summary of

the interaction or service item to review appears along with a survey rating form.


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2. To view the work item under review, click itsWork ID

3. Enter the quality ratings and reviewer comments and click Submit. The system calculates a total score and overall rating based on the ratings you enter.

link. A pop-up window opens and displays the details of the work item.

4. Review the results, and indicate whether:

A coaching session is recommended for this employee. If selected, the quality review is assigned to the employee’s manager to conduct the coaching session. If no manager is indicated in the system, the assignment is routed to the CoachingSessions workbasket.

The review is sent to the employee for comments. If selected, the quality review is assigned to the employee to review the ratings and enter comments.

System enhancements are needed. If selected, the quality review is assigned to the SystemEnhancements workbasket for evaluation of suggested changes.

5. When you are finished, click Submit.

Viewing Quality Review Results Provider Services allows authorized users to view rating information when reviewing interactions and service cases. Authorized users will see a Quality Review Summary section. To see the Quality Review case, click the Quality Review Case ID link.


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Reviewing Customer Satisfaction Surveys Based on your site’s configuration, Provider Services may send e-mail surveys to customers to measure how satisfied they were with their interactions. The system automatically scores these surveys. Completed surveys can be routed for review based on the overall survey ratings of your company.

1. Select a Customer Satisfaction Survey item from the Survey Review workbasket. A reference to the interaction type and overall survey rating as entered by the customer appears.

2. Select the Interaction ID link to open a pop-up window with details of the original interaction item.

3. Enter any review comments and click Submit.


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Conducting NPS Follow-Up Surveys When CPMHC receives a customer’s NPS rating is between 0 and 8, an NPS Followup case is automatically created and routed to the NPSSurveyFollowup workbasket.

Users who are assigned to the NPSSurveyFollowup workbasket can open an NPS Followup case and follow up with the customer in an attempt to build a better relationship with the customer.

CPMHC provides a sample NPS follow-up survey that can be configured to meet the specific needs of the business. The survey also provides segment information regarding the interaction such as the contact center, agent, work group, and other data that will inform the manager (or other designated staff) conducting the survey about pertinent information relevant to the original interaction.


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Personnel conducting the survey are also presented with options to create additional work (e.g. route to a manager for escalation, schedule a follow-up call, etc.), that will be linked to the original NPS Follow-up case.

Using Campaign Management Functions The Campaign Management area enables managers and supervisors to manage and monitor cross-sell, retention, restitution, and reward campaigns.

To Add a New Campaign From the Manager Tools tab, open the Campaign Management section and select Add New Campaign.

The system launches the Campaign wizard and automatically takes you through the steps required to create the campaign:

Step 1: Enter Rule Data 1. Enter the appropriate rule data on the input form.


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RuleSet — Contact your system administrator for the appropriate value to enter

RuleSet Version — Contact your system administrator for the appropriate value to enter

Class Name — Contact your system administrator for the appropriate value to enter

Campaign Name — Enter a name for the campaign (do not include spaces)

Product ID — Select a product ID associated with the campaign; To access a predefined set of product IDs, place your cursor in the input box and press the down arrow key

2. Click Next>>.

Step 2: Enter Campaign Data 1. Enter the campaign details.

Campaign Name — is the name you entered in Step 1

Campaign Type — use the dropdown list to select the type

Start Date — select the date the campaign is to begin

End Date — select the date the campaign is to end

Offer Repeat Frequency — enter the number of days to elapse before an offer is repeated to a customer

Offer Priority — enter the priority ranking that the system is to use if the customer qualifies for multiple offers

Fulfillment Package ID — enter a reference number or the collateral ID number to identify the information you want sent to the customer


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2. Click Next>>.

Step 3: Enter Campaign Criteria 1. Enter the Intents — the rule that defines a selection criterion.

2. Optionally, click Add New Intent to add new intents.

3. Click Next>>.

Step 4: Enter Campaign Scripts 1. Enter the names of the campaign and objection scripts to use for this campaign.


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Campaign Script — used to describe the offer; click Add/Update Script to update the script

Mail Template — select the mail template you want to use or click Add/Update Mail Template to add a new or modify an existing template

Email Template — select the mail template you want to use or click Add/Update Email Template to add a new or modify an existing template.

Objection Script — used to respond to an objection presented by the contact.

Note: If necessary, you can add multiple objection scripts.

2. Click Add/Update Script to enter or modify the text for the script. The system displays an input form.

3. Enter the text and click Save. The system returns to the Enter Campaign Scripts screen.

4. Optionally, continue to add Objection scripts or click Next >>.

Step 5: Save Campaign 1. Indicate whether you want the campaign to be available immediately.


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2. Click Finish to save the campaign.

Step 6: View Campaign Summary 1. Review the campaign details summary.

2. Click Done to complete the process and exit the wizard.

To view an existing campaign 1. From the Manager Tools tab, access the Campaign Management section and select

View Campaign Details.

2. The system displays a list of open campaigns

3. Click a campaign to display its detail in the lower portion of the screen.


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To maintain an existing campaign 1. Select an existing campaign as described in the previous section.

2. From the Campaign Details screen, click Maintain Campaign. The system displays the Campaign Wizard starting at Step 3: Enter Campaign Data.

3. Modify the campaign and complete the remaining steps of the wizard.


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Chapter 4: Understanding Provider Services Business Processing

Processing work in Provider Services is controlled by workflows. Many of the flows interact with each other and determine which screens you see and what processing occurs in the background. Provider Services includes two types of workflows: Interaction flows and Service flows.

Interaction Workflows — used when CSRs interact with customers or contacts

Service Workflows — used to process customer service requests during an interaction

Customer Management Workflows — used to maintain links between customers, contacts, and providers.

You can view these flows through the Provider Services application using the class and flow names listed in the following tables.

The flows for the business processes are configured as part of two RuleSets:

PegaCPMHC —RuleSet containing flows (and other rules) common to member and provider services

PegaCPMHCPrv — RuleSet containing flows (and other rules) specific to provider services

Interaction Flows These flows are used when CSRs interact with providers and contacts.

Note: Some interaction flows have variations for the three types of interactions. These variations can be

found in the -Call, -InCorr, and -Research classes.

Class / Flow Name Description RuleSet

PEGACPMHC-Work-Interaction

AppContactSearch Healthcare Customer Search PegaCPMHC

AppContactSearchByChannel Healthcare Customer Search (Chat) PegaCPMHC

AppContactSearchCTI Search for Contact and Provider (CTI) PegaCPMHC

AppGetWorkitem Select a Provider using Work Item PegaCPMHC

CAWelcomeMessage Sample - Deliver Welcome Message MyCoCPMHC

HCGetProvider Select A Provider or Provider Contact PegaCPMHCPrv

HCGetProviderCTI Select a Provider or Provider Contact (CTI) PegaCPMHCPrv

HCGetProvuderEntity Select A Provider Entity PegaCPMHCPrv


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HCProviderSearch Search for a Provider PegaCPMHCPrv

HCVerifyProvider Verify Provider PegaCPMHCPrv

PEGACPMHC-Work-Interaction-InCorr

AppContactSearchScanAttach Search for Contact, Provider - Inbound Corr PegaCPMHC

HCGetProviderSC Select A Provider by Number (InCorr) PegaCPMHCPrv

PEGACPMHC-Work-Interaction-Research

HCProviderSearch Provider Search - Research Interaction PegaCPMHCPrv

PEGACPMHC-Work-Interaction-Sub

HCGetProviderCTI Select A Provider or Provider Contact (CTI) PegaCPMHCPrv

The Interaction processes are related to conducting live and non-live provider interactions and are described in Chapter 3 – Working with Provider Services.

Service Workflows These flows are used to process customer service requests during an interaction.


PEGACPMHC-Work

HCGetMember Select A Member PegaCPMHC

HCGetMemberEligibilityDetails Get Member Eligibility Details PegaCPMHC

HCUpdateProviderProfile Update Provider Profile PegaCPMHCPrv

PEGACPMHC-Work-AppealAuthDenial

HCAppealAuthDenial Appeal a Prior Auth Denial PegaCPMHCPrv

HCAuthAppealResolution Process a Prior Auth Denial Appeal PegaCPMHCPrv

HCProcessAuthAppeal Process an Appeal Request For A Prior Auth Denial PegaCPMHCPrv

PegaCPMHC-Work-Correspondence

CASendCorrespondence Send correspondence PegaCPMHC

PEGACPMHC-Work-DisputeClaim

HCProcessDispute Process a Claim Dispute (Resolution) PegaCPMHC

HCSelectClaim Search For and Select a Claim PegaCPMHC

PEGACPMHC-Work-DisputeClaim-Provider

HCDisputeClaim Dispute a Claim PegaCPMHCPrv

PegaCPMHC-Work-GeneralCustomerCase

CACustomerCase Sample customer case supporting sample PegaCPMHC


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Class / Flow Name Description RuleSet Case Type process

PEGACPMHC-Work-KM-MedicareDiagnostic-Provider

HCDetermineMedicarePrimacy Determine Medicare Primacy MyCoCPMHCPrv

PEGACPMHC-Work-KM-SampleFAQ-Provider

HCProviderFAQ Sample Provider FAQ MyCoCPMHCPrv

PEGACPMHC-Work-MemberEligibility

HCMemberEligibility Review Member Eligibility PegaCPMHC

PEGACPMHC-Work-Opportunity

CAOpportunity Create New Sales Opportunity MyCoCPMHC

PEGACPMHC-Work-PriorAuthorization

HCEnterAuthorizationData Enter Authorization Request Data (Screen Flow) PegaCPMHCPrv

HCPriorAuthorization Request Pre-certification PegaCPMHCPrv

HCProcessAuthRequest Process Authorization Request PegaCPMHCPrv

PegaCPMHC-Work-ScheduleActivity

CASchedActivities Schedule an activity PegaCPMHC

PEGACPMHC-Work-ProviderAddressChange

HCProviderAddressChange Update Provider Address PegaCPMHCPrv

PEGACPMHC-Work-ProviderCredentialsUpd

HCProviderCredentialsUpd Update Provider Credentials PegaCPMHCPrv

HCUpdateCredentials Update Provider Credentials (Screen Flow) PegaCPMHCPrv

PEGACPMHC-Work-UpdateNPI

HCUpdateNPI Update National Provider Identifier PegaCPMHCPrv

The remainder of this chapter provides detailed information about the Service flows and processes. For each flow, the following information is provided:

Description of the online process and user initiated actions

Description of the business processing resulting from those actions

For details about the Interaction flows refer to Chapter 3, Working with Provider Services


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Service Flows and Business Processes The CPMHC Interaction Driver allows for grouping of service processes under various categories for logical organization and ease of navigation. The following list outlines the configured business processes in Provider Services and organized as seen below:

Category Process Name Description

General Create General Service Request

Create a general service item. Use this process to capture and route work when an automated workflow is not available

Schedule Activity Schedule a follow-up call, task, or appointment during an interaction

Determine Medicare Primacy

Sample healthcare diagnostic process – Sample use case determines Medicare Primacy based on defined business rules

Log a Complaint or Compliment

Record a complaint or compliment during an interaction and present system-determined restitution or reward offers to a customer

Send Materials / Literature Order materials (such as product collateral or company information) to be sent to a provider

Send Correspondence Generate an e-mail, fax, or mail document to a provider, based on available templates

Process FAQ Browse and search for your company’s knowledge base topics

Suggest Offers Select and present cross-sell and other offers to a contact

Provider Update NPI Update external systems with the NPI for the provider


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Category Process Name Description

Update Credentials Initiate an update to the credentialing profile of a provider

Update Address Update external systems with modified address information for the provider

Review Member Benefits Initiate a search to find a policy or member and verify the member’s plan benefit information

Request Prior Authorization

Initiate a prior-authorization (pre-certification)

Appeal a Prior Auth Denial Initiate an appeal on a previously denied prior-authorization request

Dispute Claim Payment / Denial

Initiate a dispute on a claim on behalf of a provider.

Contact Create Quick Contact Quickly add a new contact associated with a provider during phone interaction with a caller

Update Contact Profile Change the contact’s name and edit the personal profile

Update Contact Address Update contact address information Update Contact

Communication Options Update contact communication options

Create a General Service Request The General Service Request process is used to create a general service item to capture and route work when a suitable service process does not exist to process the request.

Enter Request Details This action lets you specify details about the type of service item you wish to create.

To enter request details 1. From the Take Action gadget, double click on the Create General Service

Request option under the General category. Alternatively, you can select the process and click Launch to start the process.


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2. Enter the details of the request by selecting a service type and then entering the other relevant data. Select desired response channel.

3. Click Submit.

4. A confirmation screen displays with details of the transaction. Review the information and click Close to submit for processing.


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Business Processing Provider Services routes the item to the General Service workbasket for further processing. Any user with access to the workbasket can later retrieve the item and edit it, cancel it, resolve it, attach a file, screen shot, or note. Depending on your site’s configuration, this process can be extended further to meet additional business needs.

Schedule an Activity The Schedule Activity process is used to schedule a follow-up appointment with the customer.

To specify appointment details 1. From the Take Action gadget, double click on the Schedule Activity option under

the General category. Alternatively, you can select the process and click Launch to start the process.


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2. An entry screen displays where you enter appointment and schedule information.

3. Enter the appointment details including date and time of requested callback, the topic, and select whether you wish to route the service item to a specific operator or to a workbasket queue. Depending on the selected option the system will display a list of operators or workbaskets to choose from. Select desired options.

4. Click Submit.

5. A confirmation screen displays with the case ID and relevant details about the request. Review the information and click Close to submit for processing.


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Business Processing

Provider Services routes the request to the selected operator or workbasket for further processing. Any user with access to the worklist or workbasket can later retrieve the item and edit it, cancel it, transfer the assignment, attach a file, a screen shot, or a note or resolve it

Provider Services automatically sets the overall service level goal for this activity to the date of the appointment, task, or call. Depending on your site’s configuration, this process can be extended further to meet additional business needs.


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Determine Medicare Primacy The Medicare Primacy Diagnostic process provides an example of a diagnostic process that be configured in CPMHC as a series of questions geared towards answering the customer’s queries related to a problem or situation. These questions are based on the issues / problems prioritized by your site’s business needs and configuration. More than one diagnostic process may be available on your system.

Provider Services provides a sample use case to determine if Medicare is the primary carrier in a specific situation based on a series of questions related to the member’s insurance and clinical condition.

Diagnose Issue This action lets you diagnose problems or situations defined by your site’s rules.

To diagnose an issue 1. From the Take Action gadget, double click on the Determine Medicare Primacy

option under the General category. Alternatively, you can select the process and click Launch to start the process.

2. An input screen displays that prompts the user to respond to a series of questions. As each question is answered, another question appears depending on the answer to the previous question.


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3. The question/answer process is complete when the Medicare Primacy field at the bottom of the screen appears and contains a value that determines the primary such as Submit claims to Medicare or Submit claims to Member’s Group Insurance Plan.

4. Click Submit.

Confirm Knowledge Topic This action lets you enter any additional research actions required to complete the diagnostic process. You can also enter any suggested changes to the knowledge topic. This will help improve the process in the future.

To confirm a knowledge topic 1. Confirm Knowledge Topic appears in the Take Action selection box.


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2. Respond to the prompts. Enter comments and suggestions for the topic.

3. Click Submit.

4. A confirmation screen displays with the case ID and relevant details about the case. The case is resolved unless feedback was submitted regarding the knowledge topic in which case it is pended for research. Review the information and click Close to submit for processing.

Business Processing Inquiries that require further research are routed to the General Service workbasket. Users with access to this workbasket can later retrieve the item and update it, cancel it, or attach a file, a screen shot, or a note.


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Suggested changes to topics are routed to the Knowledge Update workbasket. Users with access to this workbasket can later retrieve the item to review suggested changes and indicate whether the change should be implemented.

Log a Complaint or Compliment The Complaint or Compliment process is used to log a complaint or a compliment from a member. The process captures relevant details about the complaint or compliment and logs it in the system.

Complaint or Compliment This action lets you file a complaint or compliment for the customer.

To specify the complaint or compliment: 1. From the Take Action gadget, double click on the Log a Complaint or

Compliment option under the General category. Alternatively, you can select the process and click Launch to start the process..

2. Select whether this is a complaint or a compliment. For a Complaint, select the appropriate category, reason, and type.

3. Enter comments.


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4. Click Submit.

Confirmation of Complaint or Compliment This processing step confirms the details of the complaint or compliment and displays the case details and status.

To confirm the complaint or compliment Review the details and click Close to submit the information for processing.

Business Processing Provider Services routes the complaint or compliment to the Complaint or Compliment workbasket for further processing. Any user with access to this workbasket can later


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retrieve the item and edit it, cancel it, resolve it, or attach a file, a screen shot, or a note. Depending on your site’s configuration, this process can be extended further to meet additional business needs.

Send Materials / Literature The Material Fulfillment process is used to select material, such as marketing collateral, to be sent to a customer and let you specify the distribution method.

Select Material This action lets you select the specific material that the provider would like to receive.

To select materials 1. From the Take Action gadget, double click on the Send Materials / Literature

option under the General category. Alternatively, you can select the process and click Launch to start the process..

2. A list of sample materials displays.


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3. Select the request reason, the item(s), and enter the quantity for each item requested. If you want all of the materials in the list, click the Materials ID box in the header.

4. Click Submit.

Select Distribution Method This action lets you specify the distribution method that the customer prefers.

To specify the distribution method 1. Select Distribution Method action displays after submitting the materials selection.

2. Select the distribution method. Enter or edit the address information.

3. Click Submit.


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Confirmation of Send Materials / Literature Request This processing step confirms the details of the fulfillment request and displays the case details and status.

To confirm the Send Materials / Literature Request Review the details and click Close to submit the information for processing.

Business Processing Provider Services routes the request to the Material Fulfillment workbasket for further processing. Any user with access to the workbasket can later retrieve the item and edit it, cancel it, resolve it, or attach a file, screen shot, or note. Depending on your site’s configuration, this process can be extended further to meet additional business needs.


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Send Correspondence The Send Correspondence process is used to create and send correspondence.

Create Correspondence This action lets you specify details about who is to receive the correspondence, the format, and the type of correspondence to be sent.

Note: Provider Services includes a set of sample correspondence templates. These templates contain

predefined text, as well as fields for customer specific information. Check with your system administrator to

find out which templates are available for your company. You will need to extend this capability with your own

custom correspondence templates.

To create correspondence: 1. From the Take Action gadget, double click on the Send Correspondence option

under the General category. Alternatively, you can select the process and click Launch to start the process..

2. Select the role of the correspondent recipient. Role options include:

Contact — the party initiating the interaction (if different from the provider) Provider — the provider associated with the interaction Other Party — a third party associated with the interaction


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3. When the role is selected, additional entry fields display. Using the selection boxes, choose the correspondence and address types and the appropriate correspondence template.

The fields that appear and the choices within those selection boxes vary depending on the template that you choose. For example, if you selected Other Party as the role, fields display to enter the name and address of the other party.

4. Click Submit.

Confirmation of Correspondence Request This processing step confirms the details of the correspondence request and displays the case details and status.

To confirm the Correspondence Request Review the details and click Close to submit the information for processing.


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Business Processing Provider Services prints, e-mails, or faxes outbound correspondence items according to the type of correspondence you selected. If you selected a template that requires that the correspondence be verified prior to sending, Provider Services routes it accordingly. After the correspondence item is verified, it is distributed based on the correspondence type.

Process Frequently Asked Questions The Frequently Asked Questions (FAQ) process lets you browse and search your site’s knowledge topics that can include documents, web sites, and other content. More than one FAQ process may be available based on your site’s business needs and configuration.

Browse or Search Topics This action lets you browse or search for frequently asked questions and knowledge topics by category.

To browse topics 1. From the Take Action gadget, double click on the Process FAQ option under the

General category. Alternatively, you can select the process and click Launch to start the process..


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2. The Browse or Search for Topics screen allows you to perform a keyword search and/or browse knowledge categories to show a list of available titles.

3. Enter your search criteria and click Search to display the list of candidate topics. The topics are sorted by the number of hits - the number of times the topic has resolved FAQ inquiries for this category. Click the View Content link for a topic to view its content.

4. Click Submit.

Confirm Knowledge Topic This action lets you enter additional research actions required to satisfy the customer inquiry. You can also enter any suggested changes to the knowledge topic.

It is also called by the Frequently Asked Questions (FAQ) and Diagnostic Issue processes.

To confirm the knowledge topic 1. Confirm knowledge topic appears in the Take Action selection box.


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2. Indicate whether additional research is required to complete the inquiry and enter research notes.

3. Indicate whether the topic should be updated and suggest the change to the knowledge topic content.

4. Click Submit.

5. A confirmation screen displays with the case ID and relevant details about the case. The case is resolved unless feedback was submitted regarding the knowledge topic in which case it is pended for research. Review the information and click Close to submit for processing.


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Business Processing Inquiries that require further research are routed to the General Service workbasket. Users with access to this workbasket can retrieve the item and update it, cancel it, or attach a file, screen shot, or note to it.

Suggested changes to knowledge topics are routed to the Knowledge Update workbasket. Users with access to this workbasket can retrieve the item to review the suggestions and decide whether they are implemented.

Presenting a Suggested Offer The Suggested Offers process is used when presenting an offer to a provider. It handles the three outcomes — offer accepted, offer rejected, or more information requested. The actions that it might display are:

Process Offer

Accept Offer

Reject Offer

More Information

Confirmation of Offer Presentation

Process Offer This action lets you choose the offer to present to the customer.

To process the offer 1. Provider Services may automatically suggest and queue offers based on your

company’s business rules. These offers will be displayed under the Suggestions / To Do section of your navigation panel. To manually recommend offers, click on the Take Action gadget and double click on the Suggested Offers option under the General category. Alternatively, you can select the process and click Launch to start the process.


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2. A list of suggested offers displays.

3. Select an offer.

4. Click Submit.

Accept Offer This is the default action. It lets you accept the offer presented.

To accept the offer 1. The details of the offer display. If the customer rejects the offer, or wants more

information, select the appropriate action from the Other Actions list.


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2. Click Submit.

Business Processing Provider Services routes the request to the Opportunities workbasket for further processing. Any user with access to the workbasket can later retrieve the item and edit it, cancel it, resolve it, attach a file, screen shot, or note. In addition, the user can perform related activities that are associated with the workflow, including Send Correspondence, Material Fulfillment, and Schedule Activity (Call, Task, or Appointment).

Depending on your site’s configuration, this process may be further automated according to your company’s business needs.

Reject Offer This action lets you reject the offer presented.

To reject the offer 1. When this action displays, reject reason and comments entry fields display.

2. Select the reject reason and optionally enter comments.


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3. Click Submit.

Business Processing Provider Services closes the item with Resolved-Rejected. No further action is taken.

More Information This action lets you request more information about the offer presented.

To request more information: When this action is selected, fields are displayed to allow you to select the communication method the provider would like to use to receive the information.

4. Select the distribution method and enter/confirm the details for the selected method.

5. Click Submit.

Business Processing Provider Services routes the request to the MaterialsFulfillment workbasket for further processing. Depending on your site’s configuration, this process can be further automated according to your company’s business needs.

Confirmation of Offer Presentation This step confirms the details of the offer and displays the case number, fee charged, goal and deadline dates, and status.

To confirm the offer Review the details and click Confirm


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Update National Provider ID (NPI) The Update NPI process lets you update the provider’s National Provider Identifier.

Enter NPI Information This action lets you add/update the NPI information for the provider.

To update NPI Information 1. From the Take Action gadget, double click on the Update NPI option under the

Provider category. Alternatively, you can select the process and click Launch to start the process..


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2. The NPI data input screen displays. Enter the new NPI information.

3. Click Submit.

Note: The Dialog Manager for the NPI Information data input screen may display a coaching tip about the

specific requirements of the NPI number format. If this appears, hover over the icon to view the coaching

tip.

Confirmation of NPI Update This step confirms the details of the credentials update request and displays the case number, goal and deadline dates, and status, along with the credentials information that was updated. Based on your company’s business policy, the dialog may indicate follow-up steps that may need to be communicated to the provider.

To confirm the credentials information update Provider Services displays the updated NPI information as well as identifying information for the associated provider similar to the screen below. Review the details of the request and click Submit.


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Update Provider Credentials The Update Provider Credentials process lets you update the provider’s credentialing profile. This service process is only available for providers, not provider entities.

Enter Credentialing Information This action lets you update the credentialing information for the provider. The step is part of the Update Provider Credentials shape on the flow diagram.

To update general credential information 1. From the Take Action gadget, double click on the Update NPI option under the

Provider category. Alternatively, you can select the process and click Launch to start the process. .

2. The general credentials data input screen displays.


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3. Update the credential information.

4. Click Submit.

To update specialty certification information 1. Update Certifications appears in the Take Action box. The Specialty Information

data input screen displays.


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2. Update the specialty information. To add another specialty, click and complete the entry fields.

3. Click Submit.

To update network participation information 1. Enter Referring Provider Data appears in the Take Action box. The Referring

Provider data input screen displays.

2. Update the existing network information. To add additional networks to the list, click

and complete the entry fields.

3. Click Submit.

To update Associated Group Information 1. Update Groups appears in the Take Action box. The data input screen displays that

follows a guided flow with breadcrumb trails for each section of the data entry


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process. You can navigate between sections by clicking on any of the breadcrumb shapes at the bottom of the display.

2. Update the existing group information.

3. To add additional groups to the list, click and complete the entry fields.

4. Click Submit.

Confirmation of Credentials Information Update This step confirms the details of the credentials update request and displays the case number, goal and deadline dates, and status, along with the credential information that was updated. Based on your company’s business policy, the dialog may indicate follow-up steps that may need to be communicated to the provider.

To confirm the credentials information update Provider Services displays the details of the updated credentials information. Review the details of the request and click Confirm.


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Business Processing Provider Services routes the request to the Provider Research workbasket for further processing. Any user with access to this workbasket can later retrieve the item and edit it, cancel it, resolve it, or attach a file, screenshot, or note. Depending on your site’s configuration, these flows can be extended further to meet additional business needs.

Updating Provider Address Information The Update Provider Address process lets you update the provider’s address and other communication information.

Enter Address and Communication Information This action lets you update the provider’s address and other communication information.

To update Provider’s Address and Communication Information 1. From the Take Action gadget, double click on the Update Address option under

the Provider category. Alternatively, you can select the process and click Launch to start the process.


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2. The provider’s existing address information displays. Select an address from the list.

3. Update the address and other information. Click Update to update the information. Provider Services updates your backend systems.

4. Select another location from the list or click Submit to finish the process.

Confirmation of Provider Address Update This step confirms the address update request and displays the case number, goal and deadline dates, and status.


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To confirm the address update Provider Services updates your backend systems with the update information and displays a confirmation of the transaction. Click Confirm to return to the provider composite.

Review Member Benefits The Review Member Benefits process lets you search for a member and review the associated plan / benefit details.

Find a Member This action lets you search for a member for whom you want to review the plan / benefit information.

To search for a member 1. From the Take Action gadget, double click on the Review Member Benefits

option under the Provider category. Alternatively, you can select the process and click Launch to start the process.


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2. Find Member appears in the Take Action selection box. Select the type of search. You can search by Member ID, Last Name, First Name and Date of Birth.

3. Enter the search information for the option and click Submit. The system returns members that meet the search criteria.

4. Select the desired member and click Submit.


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Review Member Benefits This action lets you review the plan / benefit summary information for the selected member. It also provides an option to select and review additional benefit details on the member’s coverage.

Select a Product This action lets you select the desired plan from the displayed list of available plans/products on the member’s policy.

To review Member Benefit Details To review a plan benefit detail, select the desired product by clicking on it.

Product Summary Information This action lets you review the product summary information for the selected plan including general product information, cost share information, and a list of associated benefit groups. Select the desired Benefit Group to view associated benefit details.


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Benefits List This action lets you review the benefit information for the selected benefit group. It lists the key details about each of the benefits associated with the targets selected.


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Checkboxes allow you to track which benefits are discussed with the caller.

Click Submit to end the process.

Search Benefit By Name This action lets you lookup benefits by name. Select Search Benefit by Benefit Name option from the Other Actions list.

1. Start entering the desired benefit term. System will display benefits matching the text string. Select the desired Benefit and click Submit.

2. System displays selected Benefit details. Check the box to log the review with the provider. Click Submit to proceed with confirmation.

3. System displays a confirmation with the reviewed product and benefit information. Click Close to end the process.


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Request Prior-Authorization (Pre-Certification) The Prior Authorization process lets you request pre-certification on behalf of the provider.

Enter Service Request Information This action lets you enter the authorization details. The step is part of the Enter Auth Data shape on the flow diagram.

To enter Prior Authorization (Service) data 1. From the Take Action gadget, double click on the Request Prior Authorization

option under the Provider category. Alternatively, you can select the process and click Launch to start the process.


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2. The Auth data input screen displays.

3. Enter the required information about the service that you are requesting. Auth Type, Service Type, and Request Date fields are required.

4. Click Submit.


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To enter Patient data 1. Enter Patient Data appears in the Take Action selection box. The Patient

Information data input screen is displayed.

2. Enter the information about the patient for whom the prior-authorization is being requested. Patient ID is required.

3. Click Submit.

To enter / update the Referring Provider data 1. Enter Referring Provider Data appears in the Take Action box. The Referring

Provider data input screen displays. The system defaults referring provider information based on the information available about the provider on the call.


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2. Update the information about the referring provider making the request Referring Provider ID is required.

3. Click Submit.

To enter the Service Provider data 1. Enter Service Provider Data appears in the Take Action box. The Service Provider

data input screen displays that follows a guided flow with a breadcrumb trail for each section of the data entry process. You can navigate between sections by clicking on any of the breadcrumb shapes at the bottom of the display.


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2. Enter information about the service provider that is anticipated to render the service being requested. Service Provider Specialty and Last Name are required.

3. Click Submit.

Confirmation of Prior Authorization Request This step confirms the details of the prior-authorization request and displays the case number, goal and deadline dates, and status.

To confirm the prior auth request Provider Services displays the details of the prior authorization request. Review the details of the request and click Confirm to process the request.

Business Processing Provider Services routes the request to the Provider Research workbasket for further processing. Any user with access to this workbasket can later retrieve the item and edit it, cancel it, or attach a file, screenshot, or note. Depending on your site’s configuration, this flow can be extended further to meet additional business needs.

Appeal a Prior Authorization Denial The Appeal of a Prior Authorization Denial process lets you initiate and process the appeal of a previously denied authorization (pre-certification) request on behalf of the member for


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whom the service was requested. This process automatically steps you through a number of screens to complete the process beginning with a dialog script.

Communicating the Appeal Legal Process Based on your company’s policy, this action lets you inform the caller the specific regulations associated with the appeal process. The specific pre-requisite message is displayed in the dialog area of your screen.

1. From the Take Action gadget, double click on the Appeal a Prior Authorization Denial option under the Provider category. Alternatively, you can select the process and click Launch to start the process.

2. The Appeals Policies and Procedures address information displays.


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3. Communicate the message displayed in the dialog section to the caller.

4. Click Submit to continue with the appeal process.

Confirm Authorized Appealing Party This step lets you confirm the authorized appealing party based on your company’s policy.

To confirm the appealing party 1. When the screen displays, the Provider Authorized by the Member to submit an appeal option

is selected. Select the appealing party from the list.

2. Click Submit to move to the next step.

Select the Auth Request This step lets you select the desired prior-authorization record to be appealed. This step is part of the Select Prior Denial shape on the Process an Authorization Appeal flow diagram.

To select a recent authorization denial 1. Appeal Prior Authorization Denial appears in the Take Action box. A list of the

provider’s recent prior authorization denials displays.


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2. Select the authorization record from the list.

3. Using your mouse, hover over the selected record to view additional details of the record in a pop-up window.


5. The process can also be initiated by clicking the Appeal Express Action links on the list of authorizations on the Claims & Authorizations tab of the composite.


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To search for a Prior Authorization 1. When no authorization records are displayed in the list or the desired record is not

on the list, select Search for Authorization from the Other Actions. A prior-authorization search screen displays.

2. Enter the search parameters.

3. Click Submit to search for the authorization record.

4. Select the authorization record from the search result.

5. Using your mouse, hover over the selected record to view additional details of the record.



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Review Previous Appeals This step lets you review previous appeals that have been submitted for the denied authorization. This step is skipped if there no previous appeals associated with the selected prior authorization.

Submit the Appeal This step lets you submit a new appeal request and select a reason for appeal.

1. From the review screen, click Submit to initiate a new Appeal request.

2. Select a reason for the appeal and enter comments.

3. Click Submit to create the appeal request.

Note: The framework is configured to limit the number of times a denial can be appealed to 3. When

that threshold is reached, the dialog area displays a message. At this point, you can select the Cancel

this work action to end the process.

Confirmation of Appeal This step confirms the details of the appeal request and displays the case number, goal and deadline dates, and status. The original prior authorization request details are also available for review.

To confirm the appeal The details of the appeal request display. Review the appeal and click Confirm to process.


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Business Processing Provider Services routes the request to the Provider Research workbasket for further processing. Any user with access to the workbasket can later retrieve the item and edit it, cancel it, resolve it, or attach a file, screenshot, or note. Depending on your site’s configuration, these flows can be extended further to meet additional business needs.

Dispute a Claim Payment Denial The Dispute Claim Payment Denial process lets you initiate a dispute on a claim on behalf of a provider.

Start Dispute This action lets you select the correct claim for the dispute.

To select a recent claim 1. From the Take Action gadget, double click on the Dispute Claim / Payment

Denial option under the Provider category. Alternatively, you can select the process and click Launch to start the process. .


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2. A list of the provider’s recent claims displays. To view the complete claim, double click on the claim to display the details in a separate window.

3. Click Close to return to the list of claims.

4. The process can also be initiated by clicking the Dispute Express Action link on the list of claims on the Claims & Authorizations tab.


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To search for a claim 1. If the desired claim is not listed in the pre-fetched list, you can search for a claim

from the Other Actions options. You can enter the search criteria for one of these options:

Claim Number — to enter a specific claim number Member ID / Service Dates / Total Charge — to search for a claim using other criteria

Note: The claim search can also be launched from the Recent Claims section located on the provider

tab

2. Enter the required search information and click Submit. The system returns any claim that meets the search criteria.

3. When you have identified the correct claim to dispute, highlight the claim and click Submit. The system displays any previous dispute requests submitted for the claim.

Review Duplicate Dispute Requests The system displays duplicate dispute requests for the same claim. This action gives you the option of reviewing details of the duplicate requests with the customer and canceling the new request.


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To review duplicate requests 1. Review Previous Claim Disputes appears in the Take Action box. A list of prior

disputes logged for the claim displays.

2. Double-click on a row to display the details of a dispute.

3. Click Submit to create a new request. To cancel, select Cancel this work from the Take Action selection box.

Enter Dispute Reason The Enter Dispute Reason action lets you specify the reason for the claim dispute. This step is part of the Process Claim Dispute shape on the Process Dispute flow diagram.

To Enter a Dispute Reason 1. Select the correct reason from the Dispute Reason list and enter Comments.


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2. Click Submit.

Confirmation of Dispute This step confirms the details of the claim dispute and displays the case number, goal and deadline dates, and status.

To confirm the dispute The details of the claim dispute are displayed. Review the details of the claim dispute and click Confirm to process the dispute.

Business Processing Provider Services routes the request to the Provider Research workbasket for further processing. Any user with access to this workbasket can later retrieve the item and edit it, cancel it, resolve it, or attach a file, screenshot, or note. Depending on your site’s configuration, this process may be further extended according to your company’s business needs.

Create a Quick Contact The Quick Add Contact process lets you update external systems with a new contact (first-time caller) and associate the record with the provider or provider entity.


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Create Quick Contact This action adds a new contact. This option is available when you review search results for the provider or provider entity during provider interactions.

To create a new contact 1. During a provider Interaction, the system displays a list of contacts associated with

the provider if the caller is not the practitioner or is calling on behalf of a provider entity. If the caller is not listed on the search results screen, select Create Quick Contact from the Other Actions options to add the contact.

2. Enter the information for the contact.

3. Click Submit.

Business Processing Provider Services updates the external system with the contact information. This process makes an entry in the interaction log, but does not create a separate case.


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Updating Contact Profile The Update Contact Profile process lets you update external systems with modified contact name and profile information.

Update Contact Name This action changes the name and profile information for a contact.

To update a contact name and profile 1. From the Take Action gadget, double click on the Update Contact Profile option

under the Contact category. Alternatively, you can select the process and click Launch to start the process.

2. The contact’s profile data displays.


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3. Update the information.

4. Click Submit.

Business Processing Provider Services updates the external system and makes an entry in the interaction log, but does not create a separate case.


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Updating Contact Address Information The Update Contact Address process lets you update external systems with modified address information on a contact.

Update Contact Address This action changes the address information for a contact.

To update a contact address 1. From the Take Action gadget, double click on the Update Contact Address option


2. A list of the contact’s addresses that are on file display.

3. Select an address. The screen refreshes the address data.


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4. Enter the address updates.

5. To make the address the primary address, check the Make Primary box. To remove an address, check the Remove Address box.

Note: To remove the primary flag from an address, you must first designate another address as the primary address.

6. Click Update to refresh the list with the new information.

7. Continue to select and update other address types, clicking Update when each is complete.

8. Click Submit to process all changes. No confirmation screen is displayed.



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Updating Contact Communication Options The Update Contact Communication Options process lets you update external systems with contact communication information, such as additional telephone numbers or e-mail addresses.

Update Contact Communication Options This action updates the communication options for a contact.

To update a contact communication options 1. From the Take Action gadget, double click on the Update Contact Comm Options


2. The contact’s current communication options display.

3. Select the option you want to update. The current value of the options appears in the

Number/Address field. Update the field.

4. To make the selection the primary communication option, check the Make Primary box. To remove an option, check the Remove Option box.

Note: To remove a primary option flag, you must first designate another option as primary.

5. Click Update. The option is refreshed with the update.

6. Select and update additional options, clicking Update when each is complete.

7. Click Submit to process all of the updates. No confirmation screen displays.


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Chapter 5: Reporting CPMHC includes a wide variety of standard reports, graphs, and reporting tools to provide real-time information and analysis of processes, work, assignments, and historical data of customer satisfaction and contact center performance over time.

Topics are:

Reporting and Analysis Tools

Drilling Down Into Report Data

Frequently Used Reports

Creating Custom Reports

Reporting and Analysis Tools Reporting and analysis options appear on your portal when you select the Dashboard orReport Browser tabs on your Home page. The contents of these tabs change depending on the role of operator.

Dashboard— displays key metrics in interactive chart format

Report Browser — displays CPMHC reporting categories, all available reports and other reporting tool capabilities


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Dashboard The dashboard provides real-time information about key contact center activity, average promoter scores by channel, and performance in graphical formats that can be displayed in two and/or three dimensional views.

When you hover over a report, it displays details on each chart component (e.g. bar, line, pie segment, etc.).


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Report Browser

The Report Browser tab displays a number of report options on the left side of the screen and a list of the standard reports shipped with CPMHC on the right side.

Click to display detailed information about how to use features and options in the PRPC Report Browser and access tutorial videos.

Find Reports Option

Find Reports allows you to enter text strings to find and run existing reports. Results are displayed in a list on the right side of the screen.


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Create Reports Option

Create Reports launches the PRPC reporting tools and allows you to create reports and add new report categories.

Standard Reports Option

Standard Reports lists the number of standard reports in the browser by category. Select a category to display a list of those reports from which you can select and display them.

Shared Reports Option

Shared Reports lists reports that you have flagged as a shared report by report category or report owner.


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Personal Reports Option

Personal Reports lists reports that you have flagged as your personal reports.

Drilling Down into Report Data CPMHC reports include a powerful drill-down capability that enables you to move from a summary view of your entire operation down to the details of a single service request.

1. Start by selecting a report from the Report Browser. In this example, the CPMHC Promoter Results report is selected from the CPMHC Promoter Reports category on the Report Browser tab.

Note: You can also export the report data to an Excel spreadsheet. To do this, click Export to Excel

at the top of the report window.


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2. Drill down to the case detail by selecting a row in the list below the graph or clicking on the column (or other chart element). A list of the items included in the category displays in a separate window.

3. Click a row to display the work item details.

Frequently Used Reports The following table lists many of the frequently used reports included with CPMHC. A check mark indicates which reports include graphs, and whether a report appears in the view of each user role. All available reports are listed in the Report Browser.

Report Name

Description Graph

Service Mgrs

CSRs

Interaction Reports


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Report Name

Description Graph

Service Mgrs

CSRs

Interaction Channel, by Primary Reason

Displays a count of interactions for the current month and the average interaction time, grouped by the reason for interaction value.

Interaction by Channel Displays the number of interactions by channel for the current month.

Interaction by Reason Displays the number of interactions by reason (work type) for the current month.

Interaction by Operator, by Channel

Displays the number of interactions by channel, by operator for the current month.

One-Contact Analysis by Channel

Displays the number of interactions by channel broken down by whether they are related to a prior interaction, for the current month.

One-Touch Analysis by Channel

Displays the number of interactions for the current month "with open cases" and "without open cases".

Resolution Detail by Operator

Shows the number of interactions for the current month by operator, broken down by number related to prior interactions, percent related, percent not related, number with open cases, percent with open cases, and percent without open cases.

Satisfaction Summary Displays the number of interactions for the current month by reason and average interaction time.


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Report Name

Description Graph

Service Mgrs

CSRs

Satisfaction by Operator Displays the number of interactions for the current month by reason and average interaction time, by operator.

Interaction Time Trend by Reason

Displays a line chart reflecting the average interaction time by reason (i.e., work type) for the current and previous months.

Throughput Reports Throughput Summary by Work Type

Shows the number of work types opened, reopened for the current month.

Throughput by Operator, by Work Type

Shows the number of received cases, resolved cases, and open cases by operator by work type for the current month.

Throughput in Past Week by Work Type

Displays the number of cases by work type, grouped by prior cases, new, resolved, and total current cases for the past week.

Weekly Process Creation by Work Type

Displays the weekly process (work type) creation by week (current, last week, two weeks ago, three weeks ago, and so on, through to eight weeks ago).

Open Cases by Work Type Displays the number of open cases by work type at the time the report is run.

Open Cases by Assign Operator

Displays the number of open cases by assign operator at the time the report is run.


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Report Name

Description Graph

Service Mgrs

CSRs

Throughput Trend by Operator, by Day

Shows the number of received, resolved, and open cases grouped by day and operator (for the current quarter).

Throughput Trend by Operator, by Month

Shows the number of received, resolved, and open cases grouped by month and operator (for the current quarter).

Throughput Trend by Operator, by Year

Shows the number of received, resolved, and open cases for the year by operator.

Throughput Trend by Operator, by Quarter

Shows the number of received, resolved, and open cases grouped by quarter and operator (for the current quarter).

Throughput Trend by Operator, by Week

Shows the number of received, resolved, and open cases grouped by week and resolve operator (for the current quarter).

Throughput Open by Business Unit

Shows the number of open cases, by status and business unit.

Estimated Application Savings

Calculates the savings achieved using CPM by comparing the call duration for a service process against an average benchmark for the same process run in a legacy system. The time savings are then multiplied by a cost factor to apply a dollar value to the savings achieved. (See the CPM Implementation Guide for more details on how to configure this report.)

Quality Reports


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Report Name

Description Graph

Service Mgrs

CSRs

Quality Summary by Work Type

Displays the number of cases that missed their Goal SLA and Deadline SLA for the current month.

Quality Summary by Operator

Displays the number of cases by operator, grouped by # resolved in 1-day, 5-days, and reopened (for the current month).

Timeliness by Work Type Displays the number of cases within their Goal, past the Goal, and past the Deadline, grouped by work type.

Timeliness by Workbasket Displays the number of cases within their Goal, past the Goal, and past the Deadline, grouped by workbasket.

Timeliness by Operator Displays the number of cases within their Goal, past the Goal, and past the Deadline, grouped by operator.

Timeliness by Operator and Work Type

Shows the number of cases within their Goal, past Goal, and past Deadline, by operator and work type.

Ageing Reports Ageing Summary by Work Type

Displays the number of cases, by ageing (e.g. 0 days, 1 day, 2 days, 3-5 days, 6-10 days, and so on, to 61-90 days), grouped by work type.

Ageing Summary by Assign Operator

Displays the number of cases, by ageing (e.g. 0 days, 1 day. 2 days, 3-5 days, 6-10 days, and so on, to 61-90 days), grouped by operator.

Campaign Reports


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Report Name

Description Graph

Service Mgrs

CSRs

Campaign Summary

Displays the number of campaigns in the current month accepted, rejected, or required more information, by campaign (offer).

Campaign Effectiveness by Operator

Shows the number of campaigns (offers) in the current month accepted, rejected, and needed more information, by campaign.

Operator Effectiveness by Campaign

Shows the number of campaigns in the current month accepted, rejected, and needed more information, by operator.

Offers Rejected by Reason

Displays the number of rejected campaigns in the current month by work type.

Opportunity Reports Active Pipeline by Product and Stage

Displays the number of opportunties by product and sales stage (e.g. Development, Analysis, Legal, etc.).

Forecast by Rep, by Sales Cycle Stage

Displays the forecast of sales opportunities by total value, by stage and sales rep.

Annual Closed Opportunity Summary

Shows the number of closed opportunities for the current year and their value by product and sales rep.

Annual Lost Sales, by Rep, by Reason

Displays the number of lost sales for the current year by sales rep, by reason.


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Report Name

Description Graph

Service Mgrs

CSRs

Pipeline Ageing by Product Displays the opportunity pipeline by product, by day range (e.g. less than 30 days, 30 to 60 days, 90 to 120 days, etc.).

Annual Customer Opportunity Summary

Shows the number of opportunities for the current year and their total value by customer.

Active Pipeline, by Broker, by Rep

Shows the number of opportunities and their total value by broker and sales rep.

Forecast Expect Close, by Sales Cycle Stage

Shows the number of opportunities and their total value expected to close, grouped by month.

Annual Closed Opportunities, by Rep, by Month

Shows the number of closed opportunities and their total value, grouped by close month, for the current year.

Lost Sale Report, by Product and Reason

Displays the number of lost sales for the current year by product and reason.

Pipeline Ageing Report by Rep

Displays the opportunity pipeline by sales rep, total value, by day range (e.g. Less than 30 days, 30-60 days, etc.). No date parameters; reports on all opportunities in the DB.

Quality Review Management Reports Quality Review Summary by Employee and Overall Score

Displays the number of quality reviews by agent, by rating (e.g. Exceeds Expectations, Needs Improvement, etc.).

Quality Review Summary by Work Type and Overall Score

Displays the number of quality reviews by work type and rating.

Quality Review Summary by Overall Rating

Displays a summary of quality reviews by rating.


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Report Name

Description Graph

Service Mgrs

CSRs

Coaching Sessions by Employee

Displays the number of coaching sessions by employee.

Coaching Sessions by Work Type

Displays the number of coaching sessions by work type.

Quality Reviews In Progress by Work Type

Shows the number of quality reviews pending review by work type.

System Enhancement Request Summary

Displays the number of system enhancement requests by disposition (e.g. Under Construction, Scheduled for a Future Release, etc.).

Customer Satisfaction Reports Net Promoter Scores by Category

Displays the number of Net Promoter ratings by category (Promoter, Passive, Detractor) related to all resolved cases for the current month.

Net Promoter Trend by Reason for Interaction

Displays the number of Net Promoter ratings by category related to all resolved cases for the current month, grouped by interaction reason.

Net Promoter Analysis Displays the Net Promoter scores for the current month, grouped by category (Promoter, Passive, Detractor), by interaction reason and average interaction time.

Net Promoter Categories by Goal

Displays the number of Net Promoter ratings for the current month by category (Promoter, Passive, Detractor), by interaction goal.


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Report Name

Description Graph

Service Mgrs

CSRs

Customer Surveys by Interaction Type

Displays the number of customer satisfaction surveys for the current month, by interaction type

Customer Surveys by Overall Rating

Displays customer satisfaction survey ratings for the current month by rating.

Customer Surveys by Interaction Reason

Displays the number of satisfaction surveys for the current month by interaction type and overall score.

Customer Surveys by Interaction Type

Displays the number of satisfaction surveys for the current month by interaction type.

Customer Surveys One-Contact Analysis

Displays the number of satisfaction surveys for the current month that were related to a prior interaction, by overall rating.

Customer Survey Response Rate

Displays the number of satisfaction surveys for the current month by status.

Customer Surveys In Progress

Displays the number of satisfaction surveys for the current month that are in progress.

Knowledge Management Reports Knowledge Process Summary by Topic

Displays the number of knowledge processes by topic for the current month.

Knowledge Processes Requiring Research

Displays the number of knowledge processes that required further research, by topic for the current month.

Knowledge Update Request Summary

Displays the number of knowledge content update requests for the current month by knowledge topic.


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Creating Custom Reports CPMHC supports the ability to create custom reports for your application. To see detailed how-to articles, configuration tips and interactive videos about creating and customizing reports, visit the Reporting section of the PDN.

customer process manager™ for healthcare

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