Sheela for Health Plans & Payers
Automate member services, prior authorizations, and claims inquiries at scale!
Health plans face the challenge of providing exceptional member service to millions while controlling costs. Sheela enables payers to automate routine member interactions, process inquiries instantly, and scale support without adding staff. From benefits explanations to claim status checks, Sheela handles high-volume interactions with consistency and accuracy.
Key Use Cases for Payers
Benefits & Eligibility
Instant verification of coverage, benefits, deductibles, and out-of-pocket costs
Claims Status Inquiries
Real-time claim status updates, processing times, and payment information
Prior Authorization
Automated PA status checks, requirements gathering, and decision notifications
ID Card Requests
Process member ID card requests and deliver digital cards instantly
Provider Search
Help members find in-network providers by specialty, location, and availability
New Member Onboarding
Welcome calls, plan explanation, PCP selection, and portal registration
Open Enrollment Support
Handle surge in inquiries during enrollment periods with plan comparisons
Pharmacy Benefits
Formulary checks, tier information, and alternative medication suggestions
Appeals & Grievances
Initial intake of appeals and grievances with proper documentation
Advanced Payer Capabilities
Care Management Integration
-
Gap in Care Closure - Proactive outreach to members with open care gaps (mammograms, diabetic eye exams, etc.)
​
-
Chronic Disease Management - Regular check-ins with high-risk members to ensure medication adherence and symptom monitoring
​
-
Transition of Care - Post-discharge calls to reduce readmissions and ensure follow-up appointments​​
​
-
Health Risk Assessments - Automated HRA completion via phone or digital channels
Provider Abrasion Reduction
-
Provider Hotline - Dedicated line for provider offices to check eligibility, PA status, and claim information
​
-
Prior Auth Automation - Streamline PA requests with intelligent gathering of clinical information
​
-
Claim Resubmission Support - Guide providers through claim corrections and resubmissions
Benefits
Reduce Call Center Costs by 40-60%
Automate routine inquiries that make up the majority of member service calls
Improve CAHPS Scores
24/7 availability, immediate responses, and consistent service quality boost member satisfaction
Scale During Peak Periods
Handle open enrollment surges and seasonal spikes without temporary staff
Increase First Call Resolution
Instant access to member data enables resolution without transfers or callbacks
Reduce Average Handle Time
AI handles routine calls in 2-3 minutes vs. 8-10 minutes with human agents
Ensure Regulatory Compliance
Consistent adherence to CMS guidelines, state regulations, and plan policies
Regulatory Compliance
CMS Compliance
Built-in compliance with CMS marketing and communication guidelines for Medicare plans
State Regulations
Configurable to meet varying state insurance department requirements
HIPAA Security
Full HIPAA compliance with encrypted data transmission and secure storage
Audit Trails
Complete documentation of all member interactions for regulatory audits
Language Access
Multi-language support to meet civil rights and language access requirements
