This guide outlines the essential tools and steps for agents to determine a member's Out-of-Enrollment (OOE) program eligibility, understand exclusion criteria, and resolve enrollment eligibility issues efficiently.
Eligibility Investigation Workflow
When a member sees the 'No Program Eligible Screen,' agents must first investigate the cause using the following resources:
| Resource | Primary Purpose | Fallback/Contingency |
|---|---|---|
| OOE Program Feature Lookup (Looker) | Primary tool to view specific member data (claims, surveys, onboarding) that leads to program exclusion. | If Looker is unavailable or not working, reference the OOE Onboarding Logic Document to manually check exclusion criteria. |
| OOE Onboarding Logic Document | Reference document containing the explicit exclusion criteria (logic) that blocks members from enrolling into specific PayOrg programs. | Use this document to clue in on eligibility issues or present exclusions to the member if Looker data is inconclusive or unavailable. |
OOE Onboarding Logic
On the “OOE Onboarding Logic” page, you can see the onboarding exclusion criteria for each PayOrg.
The following organizations are part of the Legacy Orgs:
| SISC | ICCU | Blach | City of Monroe |
| SANA | VHS | Bass Pro | Riverside Resort and Casino |
| Qualcomm | WCU | Dassault Systemes (3DS) | Werner Enterprises |
| PayPal | Pareto Health | OSJL | Shields |
| Prudential | Outrigger Hotels | HII | AeroVironment |
Any organization not listed above and not shown on the “OOE Onboarding Logic” front page is part of the Default Paying
OOE Onboarding Logic
By using the “OOE Onboarding Logic,” we can view all the information that blocks members from enrolling into a specific program.
- OOE Onboarding Logic (click here)
- Click the name of the member’s PayOrg
- EX:
- EX:
- Note when member should see ‘No Program Eligible Screen’
-
EX:
-
OOE Program Feature Lookup
By using the “OOE Program Feature Lookup” in Looker, we can view the member information that the system is pulling from onboarding, claims, surveys, and other sources. This data may be the reason the member is excluded from all available programs. *Example UUID: c7e24684-e906-4d03-b046-f495d4f7e0e6.
- Open “OOE Program Feature Lookup” (click here)
- Paste Member’s Vida User UUID under “member_uuid” and press ‘Enter’
- EX:
-
Note: It may take a few minutes for the page to load. Be sure to remove any spaces before/after the pasted UUID.
- EX:
Inform the member
"I see you stated you have diabetes, this is why you don’t qualify for any of the programs offered through your organization”
If the member states this information is not correct, or you do not find any reason the member would be ineligible for the program when following all previous steps:
- If ineligibility is based on a condition the member self-reported, and the member confirms they do not have that condition, remove it by following these steps. Then, reattempt program selection.
If Member Should Qualify
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If there is no reason the member should be ineligible for the listed programs, escalate to ProdOps as a “[System] Service Request> Operations Support” by following the steps to report via JIRA integration on Zendesk.
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Outbound Genesys calls only: Create a Zendesk ticket first, then submit the JIRA. This ensures proper reporting and tracking.
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Outbound Genesys calls only: Create a Zendesk ticket first, then submit the JIRA. This ensures proper reporting and tracking.
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