Health-plan member support
Help members understand their next step.
Help health-plan members check benefits, request pre-authorisation or find an appointment. Ruhu follows your plan rules and uses the information returned by your connected systems.
Starts with Health Plan Member Coverage. General-insurance claims require a separate workflow.
Member support
Customer
Does my plan include this outpatient service?
Ruhu
After verifying your membership, I can check the benefit schedule and explain the conditions listed for that service.
Benefit lookup requested
Make the administrative path clear.
Examples describe health-plan administration, not medical advice. Connect benefit, provider and scheduling systems before testing.
Benefit question
Retrieve the member’s plan and benefit schedule.
Member support
Customer
Does my plan include this outpatient service?
Ruhu
After verifying your membership, I can check the benefit schedule and explain the conditions listed for that service.
Benefit lookup requested
Behind the answer
- 01
Member verified
Follow the plan’s member verification procedure.
- 02
Schedule retrieved
Read the current benefit schedule for the member’s tier.
- 03
Conditions explained
Use the listed conditions and route questions the record cannot answer.
Works with your systems
The answer comes from the source.
Your systems stay in charge of the facts. Connect the APIs this workflow needs and choose the actions the agent can take.
- 01
Membership
Verify the member and retrieve the plan tier.
- 02
Benefits
Read the current benefit schedule and administrative rules.
- 03
Providers
Check provider records and pre-authorisation requests.
- 04
Scheduling
Read clinic slots and submit confirmed bookings.
These are system categories, not a list of ready-made integrations. Availability depends on the APIs and tools configured for your deployment.
Your policy sets the boundary
Automation with clear limits.
- 01
Protect member information
Verify access before disclosing plan or appointment details.
- 02
Follow plan boundaries
Apply administrative policy and route review cases to the authorised team.
- 03
Avoid clinical inference
Do not turn administrative support into diagnosis or medical advice.
A practical starting point
Start with the workflow. Make it yours.
Adapt the procedure to your policies, connect its required tools, and test it before release.
Starts with Health Plan Member Coverage. General-insurance claims require a separate workflow.
Shipped starting templateHealth Plan Member CoverageView workflow
A chat-first member-services agent for a health plan (HMO). Verifies the member with a two-factor check (member ID + date of birth), then routes to the right path: plan coverage lookup on the tiered benefit schedule, pre-authorisation request with in-network provider check and policy-driven approve / review / deny, or appointment booking against real clinic capacity.
A template provides the procedure. Your team configures the connections and reviews what the agent may do.
Define success together
Measure the work that matters.
Agree on a baseline and a focused pilot. Review outcomes alongside exceptions and customer feedback.
- 01
Benefit clarity
Did the member receive an answer grounded in the plan schedule?
- 02
Review completeness
Did the authorised team receive the required request details?
- 03
Booking accuracy
Did reported bookings match the scheduling system?
Suggested pilot measures, not published customer results.
Before you start
Questions teams ask.
Is this a general-insurance claims template?
No. The shipped template is Health Plan Member Coverage, covering benefits, pre-authorisation and appointment paths. General-insurance claims need a separately configured workflow.
Does Ruhu give medical advice?
These workflows handle plan administration. Clinical questions should follow your designated care or escalation pathway, not be inferred from a benefit record.
Who sets the pre-authorisation rules?
Your plan supplies the policy, provider connections and review boundaries. Configure the administrative approval and referral paths before testing the workflow.
Start with one workflow
Make a member’s next step easier to understand.
Bring a benefits, pre-authorisation or scheduling procedure. We’ll identify the records and review boundaries it needs.