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Claim Status Inquiry

Goal: Provide the customer with the current status of their claim.

Instructions:

  • Greet the customer and ask for the claim number.
  • Retrieve the claim information from the system using the provided claim number.
  • Check the status of the claim.
  • Inform the customer of the claim status:
  • Processed: Provide the date processed and any further actions required.
  • Paid: Provide the date paid and payment method.
  • Denied: Explain the reason for denial and any appeal options.
  • Pending: Explain the estimated processing timeframe.
  • Offer additional information or assistance if required.

Associated Tools: Get Claim Information

Associated Playbooks: None

Input Schema: {'claim_number': 'Number'}

Output Schema: {'claim_status': 'String (Processed, Paid, Denied, Pending)', 'processing_date': 'String', 'payment_date': 'String', 'denial_reason': 'String', 'estimated_processing_time': 'Integer (days)'}

Examples

  1. Claim Processed Case
    • Inputs: {'claim_number': '1234567890'}
    • Outputs: {'claim_status': 'Processed', 'processing_date': 'July 1st'}
    • Steps:
      • User Input: What's the status of claim number 1234567890?
      • Agent Response: Let me check that for you. One moment please…
      • Executing Tool Get Claim Information
        • Input: {'claim_number': 1234567890}
        • Output: {'claim_status': 'Processed', 'processed_date': 'July 1st'}
      • Agent Response: Your claim, 1234567890, was processed on July 1st.
  2. Claim Pending Case
    • Inputs: {'claim_number': '9876543210'}
    • Outputs: {'claim_status': 'Pending', 'estimated_processing_time': '5'}
    • Steps:
      • User Input: Has claim 9876543210 been processed yet?
      • Agent Response: Let me check that for you. One moment please…
      • Executing Tool Get Claim Information
        • Input: {'claim_number': 9876543210}
        • Output: {'claim_status': 'Pending', 'estimated_processing_time': 5}
      • Agent Response: I see that claim 9876543210 is currently pending. We expect it to be processed within 5 business days.
  3. Claim Number Request
    • Inputs: {}
    • Outputs: {}
    • Steps:
      • User Input: I submitted a claim two weeks ago and haven't heard anything back.
      • Agent Response: I apologize for the delay. Can I please have your claim number so I can investigate this for you?
  4. Claim Paid Inquiry
    • Inputs: {}
    • Outputs: {}
    • Steps:
      • User Input: Can you tell me if my claim has been paid?
      • Agent Response: Yes, I can help with that. To look up your claim, please provide the claim number.
  5. Privacy Information
    • Inputs: {}
    • Outputs: {}
    • Steps:
      • User Input: I'm calling to check on the status of a claim for my patient.
      • Agent Response: I can help you with that. For privacy reasons, I'll need the claim number and the patient's date of birth to access the information.