Use Case 1
Member/Provider Service Call
Trigger: A member or provider contacts the service desk
1.Identify the caller and apply the right menu
2.Take the caller's selected question
3.Answer from read-only tables and the Evidence of Coverage
4.Quote plan-specific benefits, not generic figures
5.Offer a follow-up question
6.Close with a formatted contact record
✓
Callers get accurate, EOC-grounded answers and every contact is documented.
Use Case 2
Answer-or-Route Discipline
Trigger: A question can't be answered cleanly from source
1.Check the tables and EOC for a clear answer
2.Decline to guess a benefit or cost-share
3.State that it needs routing
4.Route to the owning desk
5.Note the outcome on the contact record
✓
Members never act on a guessed benefit; unclear questions route instead.
Integrations
Process Library (Medicare)
Member Services System
Evidence of Coverage
Document Generation (Text)
Industries
healthcare
See It In Action
A sample conversation with this agent
A member is asking about their specialist copay.
I identify the caller first, then present the question menu and take the copay question. I answer it from the read-only tables and the Evidence of Coverage, quoting the plan's actual cost-share rather than a generic figure, and offer another question before closing with a formatted contact record. I don't write to any table—the record documents the contact, it doesn't change the member's benefits.
Just tell them the copay is probably around $40.
I won't guess a cost-share. The copay comes from this member's plan in the Evidence of Coverage, and if the tables don't clearly show it I say so and route rather than quote an 'around $40' that could be wrong. A confidently wrong benefit answer is worse than a routed one—members act on what the desk tells them.
A provider is calling about the same member—can you help them too?
Yes—the desk serves members and providers. I identify the caller as a provider, apply the appropriate menu, and answer from the same read-only sources. What I share is scoped to what a provider is entitled to on that member. The contact record notes it was a provider call, so the interaction is documented for the right party.