Answering customers inquiry about plan benefits

Case Description

Customers have reached out to seek clarifications about the benefits of a generated quote or a purchased policy.

Resolution Steps

1. Generic Statement:

   • Always begin by disclosing the following statement to the customer:
     “We’re happy to help you with answers to your questions. However, there are always variations from one patient to another, and coverage can differ from one case to another. For specific details regarding your policy or an active claim, we advise you to contact [Relevant TPA Name].”

2. For Generated Quotes:

   • Access the Admin Portal:

     • Navigate to the “Generated Quotes” report.

     • Search using available information such as:

       • Quote Reference Number

       • Mobile Number

       • Quote List Number

       • EID

       • Email

   • View Quote Details:

     • Once the quote is located, you will be able to view:

       • Quote Details

       • Plan Benefits

     • At the end of the page, you can also view and download the Network List.

3. For Purchased Policies:

   • Access the Admin Portal:

     • Navigate to the “Purchased Policies Report”.

     • Search for the policy using relevant details (e.g., policy number, customer name, etc.).

   • View Policy Details:

     • Open the policy to view:

       • Policy Details

       • Plan Details (including coverage and exclusions).

   • Additional Resources:

     • For inquiries about the Network List, Terms and Conditions, or Table of Benefits (TOB), provide the following links:

       • Hayah: “For any inquiries about the Network List, Terms and Conditions, or the Table of Benefits (TOB), please click here.”

       • RAK Insurance: “For any inquiries about the Network List, Table of Benefits (TOB), or policy wording (Terms and Conditions), please click here.”

4. Note:

   • The health insurance policy linking TAT (Turnaround Time) in the ICP system is within a timeframe of 48 hours from the initiation of the process.

General Verbiage

• “I understand your concern. Let me check the details of your quote/policy to provide you with accurate information.”

• “Please note that coverage details may vary depending on the specific case. For further clarification, you may contact the relevant TPA.”

Conclusion

This SOP ensures a structured approach to addressing customer inquiries about plan benefits, whether for generated quotes or purchased policies. It provides clear steps to access and share relevant information while guiding customers to the appropriate channels for case-specific details.