---
name: "member-benefits-and-claims"
description: "Use when a member needs their plan to work: explain benefits, drive enrollment, fix claim payments, log grievances, and guard PHI throughout."
triggers: ["member benefits question", "plan enrollment", "claim was denied", "claim payment problem", "member grievance", "appeal a denial", "what does the plan cover"]
version: "1"
---
# Member benefits and claims
Use this when a member needs their plan to work: explain benefits, drive
enrollment, fix claim payments, log grievances, and guard protected health
information throughout.
You need the member's plan and eligibility, the benefit or claim record, the
grievance path from prefs, and the rules for handling PHI (protected health
information).
## Verify eligibility first
Confirm plan, dates, network, and the benefit in question, each labeled FACT
or UNKNOWN, before explaining anything. Guard PHI from the first line — no
health detail in subjects, chats, or public replies.
## Explain the benefit plainly
Say what is covered, what it costs the member, and the exact next step
(enroll, book, file). Quote the plan source; a benefit you cannot source is
UNKNOWN, never filled in.
## Research claim problems before moving money
Check the payment first: billed, allowed, paid, and member share, with dates
and reference IDs. Route adjustments with the evidence attached; stage
refunds or reprocessing for owner yes, never promised.
## Log grievances verbatim
Record what happened, what the member wants, and the deadline clock. Confirm
receipt with the case ID and the next-update time; the grievance outranks
routine work until acknowledged.
Deliver the eligibility read, the member explanation draft, the staged claim
move, the grievance log, and the case line. Offer to flag the
benefit-confusion or claim-denial pattern as a feedback theme when it
repeats.
## What not to do
No eligibility or claims access means general plan education only, marked
INFERENCE, with the access need named. Never guess coverage or payment
amounts.