0
Phase 0: Latest Care Encounter Check-in
The system surfaces the member's most recent care encounter as a personalised, data-driven conversation opener. It collects structured post-encounter intelligence across six dimensions and provides the insurer's network department with first-hand market provider data from real member experiences.
- ▸Retrieves the member's latest care encounter from connected health record or claims data
- ▸Surfaces encounter details: provider, date, diagnosis category, and any open follow-up actions
- ▸Opens with a contextual, personalised check-in rather than a generic prompt
- ▸If no recent encounter exists, the system transitions directly to Phase 1
- ▸Phase 0 encounter data feeds the provider intelligence and feedback collection layer in Phase 3
What Phase 0 Collects From Members
Facility Experience
- ▸Physical facility cleanliness and hygiene
- ▸Infrastructure quality and equipment condition
- ▸Accessibility and parking availability
- ▸Comfort and privacy of the care environment
- ▸Signage, navigation, and check-in ease
Physician and Clinical Quality
- ▸Doctor attentiveness and listening quality
- ▸Consultation duration and thoroughness
- ▸Clarity of diagnosis and treatment explanation
- ▸Bedside manner and empathy
- ▸Clinical confidence and competence rating
Waiting and Access Times
- ▸Appointment booking lead time in days
- ▸In-clinic waiting time before consultation
- ▸Consultation duration vs. expected time
- ▸Discharge and administrative processing time
- ▸Same-day appointment availability signals
Support Staff and Administration
- ▸Reception and front-desk professionalism
- ▸Nursing staff care quality and attentiveness
- ▸Insurance and billing coordination quality
- ▸Communication of rights and procedures
- ▸Complaint and concern handling
Care Coordination and Follow-up
- ▸Post-appointment follow-up communication
- ▸Prescription clarity and pharmacy coordination
- ▸Referral handling and specialist communication
- ▸Lab results communication timeliness
- ▸Care continuity between visits
Overall Satisfaction
- ▸Overall visit satisfaction score (1 to 5)
- ▸Likelihood to recommend the provider
- ▸Whether the member would return to this provider
- ▸Value for money perception
- ▸Free-text commentary on standout issues
How This Enriches the Network Department
- ✦Provides first-hand, real-time market intelligence from actual member encounters, not static network directories or self-reported provider data
- ✦Identifies underperforming providers early, before contract renewal cycles, based on consistent member signals across multiple dimensions
- ✦Tracks facility capacity signals (consistently long waiting times indicate overloaded providers or understaffed facilities) at a network-wide level
- ✦Powers the provider search quality ranking visible to members in Phase 1, creating a direct feedback loop between quality signals and provider discoverability
- ✦Enables the network team to make data-driven provider partnership decisions, tiering, and inclusion/exclusion based on verified member experience rather than subjective criteria
- ✦Surfaces geographic coverage gaps where member satisfaction is consistently low, indicating a need for alternative providers in that area or specialty
- ✦Enables quality benchmarking across providers within the same specialty and network tier, supporting fair and data-backed performance conversations with providers
- ✦Feeds compliance and quality assurance dashboards accessible to the operations and network teams without the need for separate manual audit processes
Business Outcome
- ▸Higher member engagement through personalised conversation openers
- ▸Proactive surfacing of follow-up service needs before the member asks
- ▸Network department gains a live, scalable provider intelligence stream
Analytics Signal
- ▸Encounter recency, follow-up rates, and unresolved care needs
- ▸Phase 0 to Phase 1 transition speed and trigger type
- ▸Provider rating distribution by specialty, region, and network tier
1
Phase 1, Service and Inquiry Fulfilment
Anchor Phase
The core of the platform. Handles every real service request a member, broker, or agent brings to the system. The system always returns to Phase 1 after completing Phase 0, 2, or 3 if a service need remains.
- ▸Handles 28 insurance-specific intents across authorization, claims, policy, provider, reimbursement, and escalation categories
- ▸Deterministic-first resolution: structured workflow logic runs before any AI invocation
- ▸AI mode controlled by runtime policy: DETERMINISTIC ONLY, HYBRID ASSISTED LOCAL, HYBRID ASSISTED AZURE, or LLM DISABLED
- ▸All intent classifications and resolution outcomes are logged for audit and analytics
- ▸The system remains in Phase 1 as long as the user has active service requests and does not move on prematurely
- ▸Escalation routing, case creation, document upload, and external handoff all originate from Phase 1
Business Outcome
- ▸Self-service deflection of routine inquiries from call center
- ▸Transparent, auditable service resolution
- ▸Faster fulfilment across authorization, claims, and policy requests
Analytics Signal
- ▸Intent distribution and volume by category
- ▸Resolution rate vs escalation rate
- ▸AI mode usage and LLM invocation frequency
2
Phase 2, Extended Services
After the primary service need is resolved, HealthCopilot opens a contextual window for extended digital services tailored to the member's situation and the insurer's configured marketplace.
- ▸Triggered only after Phase 1 resolution is confirmed. Service needs always come first.
- ▸Contextually relevant offers based on the resolved Phase 1 intent and member profile
- ▸Configurable marketplace: the deploying insurer or TPA defines which extended services are available
- ▸Example services: appointment scheduling, lab ordering, telehealth referral, wellness programme enrolment
- ▸Future service extension capability: new services can be added without platform re-architecture
- ▸Phase 2 acceptance data feeds back into the analytics and improvement loop
Business Outcome
- ▸New service monetisation opportunities for the insurer
- ▸Higher member engagement beyond transactional inquiries
Analytics Signal
- ▸Extended service uptake rate by type
- ▸Phase 2 conversion by prior Phase 1 intent
3
Phase 3, Satisfaction Feedback
Structured in-conversation collection of member satisfaction with TPA and insurance services. Captures how members feel about coverage adequacy, policy clarity, claims handling, communication quality, and the digital service experience. These signals feed continuous service improvement, policy design, and member retention analytics.
- ▸Triggered after Phase 1 service resolution, capturing satisfaction while the experience is still fresh
- ▸Covers TPA and insurer service quality: response speed, resolution satisfaction, staff communication, and escalation handling
- ▸Captures coverage adequacy perception: whether benefit limits met the real clinical need, out-of-pocket surprise, and perceived gaps
- ▸Measures policy clarity: whether exclusions were understood, how accessible documentation is, and whether the member felt informed
- ▸Assesses claims handling satisfaction: approval time, rejection justification clarity, reimbursement process smoothness, and appeal transparency
- ▸Negative signals trigger operational alerts, escalation case creation, or targeted outreach workflows in the operations dashboard
- ▸Aggregate satisfaction data surfaces in the operations analytics dashboard, segmented by product, region, and member cohort
What Phase 3 Collects From Members
Insurance Service Quality
- ▸Speed of service response and resolution
- ▸Staff communication and responsiveness
- ▸Escalation handling and case follow-through
- ▸HealthCopilot interaction satisfaction score
- ▸Overall TPA service experience rating
Coverage Adequacy
- ▸Whether benefit limits met the real clinical need
- ▸Out-of-pocket cost satisfaction
- ▸Coverage gaps encountered during care
- ▸Adequacy of chronic or specialist coverage
- ▸Premium value perception
Policy Clarity
- ▸Understanding of coverage terms before the visit
- ▸Exclusion clause clarity and awareness
- ▸Policy change notification quality
- ▸Accessibility of policy documentation
- ▸Language and readability of policy language
Claims Handling
- ▸Approval time satisfaction
- ▸Rejection justification clarity
- ▸Reimbursement process smoothness
- ▸Document submission experience
- ▸Appeal process transparency
Digital Channel Experience
- ▸Interface ease of use and navigation
- ▸Language preference accommodation
- ▸AI response accuracy and relevance
- ▸Speed and completeness of self-service resolution
- ▸Trust and data privacy perception
Overall Insurance Satisfaction
- ▸NPS score for the insurer or TPA
- ▸Likelihood to renew the policy
- ▸Likelihood to recommend to others
- ▸Value for money perception overall
- ▸Free-text commentary on standout issues
How This Enriches Operations and CX Teams
- ✦Replaces slow, low-response annual surveys with real-time, in-conversation satisfaction signals collected at the point of service resolution
- ✦Identifies policy and coverage design gaps through repeated member signals, giving the product team evidence for plan redesign before renewal cycles
- ✦Surfaces claims process friction points at scale, enabling the claims operations team to target process improvements based on member experience rather than internal assumption
- ✦Provides a member retention early warning system: negative satisfaction trends at cohort level are visible in the operations dashboard before they translate into churn
- ✦Enables benchmarking of satisfaction by product tier, region, employer group, and member cohort to identify where service investment will have the highest impact
- ✦Supports regulatory and audit requirements for documented member satisfaction monitoring without manual data collection or outsourced survey programmes
Business Outcome
- ▸Continuous TPA and insurance service quality improvement
- ▸Data-driven policy and product design at renewal
- ▸Early warning for member retention risk at cohort level
Analytics Signal
- ▸NPS and satisfaction score by product, region, and cohort
- ▸Policy clarity and coverage adequacy perception trends
- ▸Claims process satisfaction and friction point distribution
The Anchor Principle
Phase 1 is the centre of gravity. After any Phase 0 check-in, Phase 2 extended service offer, or Phase 3 feedback collection, the system checks whether the user has a remaining service need. If they do, or if they introduce a new one, the system returns immediately to Phase 1. HealthCopilot never moves on from service delivery until service delivery is complete.