Blender Workflow Tasks

Blender Workflow Tasks

Review the following slides to see what tasks you will need to review when settling claims.

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Understanding Workflows

In Blender, you'll be working out of the Workflows tab. Workflows is a set of specific tasks that CLX Claim Advocates, CLX Pet Specialists, and potentially UW Associates will complete. As a CX Specialist, you'll be focusing on tasks that a CLX Pet Specialist would ordinarily complete including the:

• Settlement Email
• Item Review & Payment

You will also need to review the Final EIPD task, but that is completed by the CLX Claim Advocate prior to being sent to CX Specialists for completion. On the image to the right, click on the tasks next to the "Click" icon to learn more! There are other tasks that you will likely open when settling a claim to gather additional information, but we'll talk about those in detail later!

Final EIPD

The Final EIPD task is the summary of the outcome of the claim completed by the Claim Advocate. In here you will find:

• The claim outcome (e.g. eligible, not eligible, or "split")
• What exclusions, if any, there were on the claim
• If any limits were met (e.g. annual limit, item limit, add-on limit)
• If any taxes or biohazard fees were applied to any items
• The denial letter that MUST be included in the Settlement Email (if it's a denial)
• The cost breakdown, which includes information about the deductible and reimbursement

What Is EIPD?Click Here!

Final EIPD

Click below to discover more information about this task!

Settlement Email

The Settlment Email task is where you will send the final email to the policyholder. This is where you will select the most appropriate macro and fill out all of the necessary information. It will automatically carbon copy over to the Comms Timeline.

Click Here!Important

We'll discuss more about selecting macros shortly!

Items Review & Payment

Once you've sent the email and closed the Settlement Email task, you can proceed with the Items Review & Payment task. This is where you will close the claim (denial, partial coverage, or reimburse). The Claim Advocate should have rejected all that needed to be rejected in a previous task, but you should always double check and compare with the exclusions in the Final EIPD task.

We'll discuss more about settling the claim shortly!

The cost breakdown provides an overview of:

• What was excluded (if the whole claim was excluded, it will be the same as the total cost)
• What is remaining after any exclusions (it will show as $0 if a full denial)
• What the deductible was before and after this claim
• What we are reimbursing the policyholder, if anything

We always need to make sure the policyholder is well informed about the monetary portion of the claim. This section may need to be used to fill out bits of information in certain macros. In addition to being included in the task note, you can also find the cost breakdown at the top of the Final EIPD task in a dropdown menu. They should be identical (see below).

The Settlement Email task will always appear "blank" because it has not been completed yet, but it is the next task that should be completed. This is the task where you will send the final email to the policyholder. You will see your avatar next to this task or the original Pet Specialist who was going to complete the task before it was reassigned.

To see why a line item was rejected, you can just hover over the info prompt. If you ever need help explaining why an item has been rejected in the Settlement Email (prior to sending), you can look at the rejected infromation in the Review Claim Items task. It should be identical to this task.

Important: Before settling a claim, you must ALWAYS check to see if the pet has multiple open claims. We always want to settle all claims at once and include all information in a single settlement email. Otherwise, we could bombard a policyholder with numerous repetitive emails, which isn't a great customer experience. To see if there are open claims, you can go the the Claim Overview dropdown in Workflows and the Claim History section. Look to see if there are any additional OPEN claims. If there are, you will use the OLDEST open claim to send the settlement email.

Active means that the item is eligible for coverage. As stated previously, if it looks like an item that was supposed to be excluded based on the Final EIPD task, you will want to check with the Claim Advocate. Otherwise, any item marked as 'Active' will either be applied to the deductible and/or reimbursed to the poliyholder. In the example below, all items are eligible for coverage.

By hovering over the avatar next to each task, you can see who completed it or who was assigned the task. Your avatar will appear next to the Settlement Email task and the Item Review & Payment task.

The Item Review & Payment task should be a yellow-ish collar with three horizontal dots. This indicates that the task is pending. That's because you must always send the settlement email BEFORE closing the claim in the Item Review & Payment task. This task will automatically open once the Settlement Email task has been completed. ***It may be blank like the Settlement Email task and that's ok! That just means the task is already open.

The Medical Denial bullet point will appear if the claim requires documented proof as to why the condition isn't eligible for coverage. This is done for claims that were denied due to:

• The condition was pre-existing
• The treatment was not medically necessary
• The condition was a recurring condition and they hit their "third strike"
• The condition was a bilateral condition

If the Final EIPD task has a medical denial letter, it MUST be embedded into the macro that will be sent in the Settlement Email task. It must be verbatim to what the Claim Advocate wrote, but can be reformatted to be aesthetically pleasing within the macro.

The Claim Determination of the Final EIPD task will dictate what kind of macro you'll be sending the policyholder. You will be seeing different types of claims including, but not limited to,

• Claims that are eligible but certain items might not be
• Claims that aren't eligible at all
• Claims that are partially eligible and partially ineligible (these are "split" eligibility claims)
• Claims that are applied to the deductible
• Claims that have maxed out the annual or an item limit

As such, you need to know what the outcome was so you can properly relay that information to the policyholder. Being transparent at the time of closing the claim will save the policyholder from having to call or email back about what wasn't covered or why something wasn't eligible for coverage.

The Final EIPD should always have a green check mark to the left of the task. That indicates that it is completed. If you do not see that the Final EIPD task has a green checkmark, the claim should go back to the Claim Advocate (this should be rare). If you see a blue-ish star to the right of the task, that means it was completed by AI. Rest assured, the Claim Advocate made all previous determinations, which is what led to the AI completing the Final EIPD task. We'll discuss more about this task shortly.