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Customer Guide for
Healthcare Payers
Salesforce Spring

salesforcedocs
Last updated December

names and marks Other marks appearing herein may be trademarks of their respective owners

CUSTOMER GUIDE FOR HEALTHCARE PAYERS

Create humancentered experiences across all health and life science touchpoints
The assets in this Customer Guide help healthcare payers build a vision and make a plan for digital transformation Learn with
Trailhead
Architectural diagrams and business scenarios show you how Salesforce products combine with industry best practices to expand your
business capabilities Solution Kits show you how to implement Salesforcerecommended crosscloud solutions to common retail use
cases
Industry Blueprint for Healthcare Payers
Examine the Salesforce view of strategy product innovation and partner relationships to enable frontend and backend business
processes in the healthcare payer business
Reference Architecture for Healthcare Payers
Map specific Salesforce products to the functional capabilities and operational activities of healthcare payer organizations
Business Scenarios for Healthcare Payers
Business scenarios help you bridge the gap between your organizations business capabilities and the solutions that can set your
organization on a course to achieve its goals For each scenario discover a variety of Salesforce solutions that can reduce your time
to value and help define a roadmap to build out your organizations functionality
Solution Architecture for Healthcare Payers
Identify the specific tools and resources that can help you deliver comprehensive automation solutions for healthcare payer
organizations
Explore Solution Kits for Healthcare Payer Organizations
Enhance your crosscloud business by implementing one or more solution kits Get product recommendations workflow details
and instructions to help you implement the solution from start to finish

Platform Enablers API and Data Sources are common across all lifecycle stages and business processes Use platform enablers APIs and

data sources as a baseline of functionality to support tailored solutions

Customer Guide for Healthcare Payers

Reference Architecture for Healthcare Payers

Note To understand how industry and business requirements link to the underlying technologies that support them review the
Reference Architecture for Healthcare Payers Use the industry blueprint as a framework for creating a reference architecture for
planning customer experience enhancements

BB systems typically rely on these elements

Customer Guide for Healthcare Payers

Reference Architecture for Healthcare Payers

Data Sources
Data sources are systems that create collect and manage various types of data These systems can act as systems of record Theyre
often purposebuilt to handle particular functionality and data requirements but some provide general system needs
Integrations
Integrations include tools and routes that connect systems of record with each other or with higherlevel experiences Integrations
can include varied tools like APIs that connect separate systems single signon services to manage customer identity across different
systems and customer data platforms that segment customers
Intelligence

Smart automation like machine learning and AI helps you optimize your use of customer data To enhance your customer relationships

and drive sales the intelligence layer serves functions like delivering actionable customer insights personalized product
recommendations and improving realtime customer interactions
Analytics
Analytics helps you better understand your data and make smart business decisions
Descriptive analytics summarize existing data to help you better understand the current state or past activities Descriptive
analytics typically answer What questions about your data
Diagnostic analytics use the output of descriptive analytics to identify patterns and outlier data Diagnostic analytics typically
answer Why questions about your data
Predictive analytics use historical data to anticipate future outcomes such as the likelihood that a subscriber opens an email
Prescriptive analytics suggest courses of action based on your existing data Prescriptive analytics typically answer Should
questions about your future actions
Platform Enablers
Use common capabilities that drive the business processes across the enterprise Build a unified profile using a customer data
platform Drive workflows and engagement based on that unified profile

Functional Capabilities
Businessspecific elements at the functional capabilities level are connected more directly to the customers experience and measured
in terms of maturity Successful implementation of functional capabilities depends heavily on implementation of the platform capabilities
The member lifecycle typically crosses multiple engagement channels in the areas of marketing sales support care programs selfservice
and commerce In addition to customer service payers provide a continuum of care for their members Improving the overall experience
from service to personalized care is essential for payers to retain and delight their members There has been an industry shift to creating
a holistic view of each member in order to provide the most relevant and timely information for agents as well as reduce costs through
efficient integration and data alignment
To identify strategic goals around which to focus your implementationreview these commonly required functional capabilities to identify
strategic goals around which to focus your implementation

A Business Capability Maturity Assessment arranged by your Success Manager or Account Executive can help you determine which areas

of your business can benefit from more focus

Customer Guide for Healthcare Payers

Business Scenarios for Healthcare Payers

Mapping Platform Capabilities to Salesforce

Specific Salesforce products handle each of the needs identified at the platform capability level
Identify gaps in your underlying capabilities by customizing this model to include other Salesforce products or thirdparty systems in
your current technology stack
To explore the reference architecture specific to your business contact your Success Manager or Account Team
Tip Business Scenarios for Healthcare Payers on page help you better understand your business capabilities and find solutions
that support your business goals

Improved per member per month revenue PMPM

Increased member agent and employer satisfaction ratings
Increased percentage of member capture in transition between business lines
Process KPIs

Data to support process KPI metrics can be pulled from Salesforce reports

Reduced days to acquire
Decreased cycle time for quotetocard process
Decreased cost per acquisition
Increased percentage of messages opened
Increased conversion from messages
Decreased average time to enroll
Decreased number of cases per enrollment
Increased number of selfservice transactions
Increased number of no touch transactions
Decreased time for first call resolution

Products
These products can help you optimize your reach and acquisition capabilities
Health Cloud
Marketing Cloud
Experience Cloud for Healthcare
for healthcare
Shield
Platform
Salesforce Industries

CRM Analytics for Healthcare

Mulesoft optional

CDP optional

BC Commerce optional

Enablement Sites myTrailhead optional

Business Capabilities
To create positive customer experiences while increasing organizational efficiency implement technical solutions and best practices
that can enhance your business capabilities

Customer Guide for Healthcare Payers

Optimize Healthcare Payer Reach and Acquisition

Target and Engage New and Existing Members
Grow your member base in the increasingly competitive payer space with relevant and timely outreach Divide existing members
and prospective members into logical segments to better understand needs inform customer experience strategy and align support
strategies Reach out to customers to provide information education and support based on actions taken online benefits used or
through a member support agent
Help Members Research Compare and Select Health Insurance
Apply experience design principles and testing methods to create an intuitive shopping experience that helps members research
doctors medications benefits and costs Support conversion and retention by providing support at key moments especially when
a new member is stalled in a purchasing journey
Simplify and Automate Sales and Administration
Reduce operational costs and streamline enrollment by automating sales quoting and underwriting for sales agents and setup for
group sales administrators Improve agent productivity and member satisfaction by providing each agent with proactive contextual
information about each member customer Increase revenue opportunities by partnering with and supporting brokers
Solutions for Optimizing Reach and Acquisition
These solutions support capabilities within the Optimize Healthcare Payer and Reach business scenario in the Customer Guide
for Healthcare Payers For details about capabilities tied to these solutions review each business scenario separately

CAPABILITY

BEST PRACTICES

Campaign Planning
Align on company business goals and key performance
Work across departments including sales administration
indicators
member services broker enablement and care management To extend reach create multichannel campaigns
to define and align on campaign and promotion strategy
Ensure a consistent experience by defining campaign planning
across all channels
Use member and prospect data when planning campaigns
Channel Strategy and Mix
Align the channel strategy with the organizations wider
Target customers with products services marketing and
gotomarket strategy
channels usually including direct sales email social media Collaborate with sales marketing business units and other

marketing call centers BB commerce and partner relationship

key leaders to define a clear channel strategy Align with the
management
overall gotomarket strategy
Establish the role objectives and targets of each channel
Establish a framework for deciding the optimal customer
product and channel combinations for serving customers
Design for the downstream effects of the channel strategy on
your sales capability and the wider business
Create a consistent customercentric experience across
channels
Create a uniform buying experience within and across channels
Use design thinking and customercentric processes to build
experiences that align with how customers behave Align with
their preferred way of being served wherever possible
Lifecycle Marketing
Tailor marketing messages based on each stage of the
customers lifecycle and touchpoints

Define the lifecycle of the customer by industry or organization

A basic lifecycle consists of awareness acquisition onboarding

engagement and retention
Define customer needs and moments that matter to customers
at each stage of the lifecycle
Develop a welldefined customer lifecycle and use it to
orchestrate messages across touchpoints
Use analytics to place contacts leads prospects or customers
in a lifecycle stage
Develop a set of tactics for each stage of the lifecycle that
addresses customer needs and company goals For example
assign lapsed customers a winback campaign when they
havent opened or clicked an email in the past months

Customer Guide for Healthcare Payers

CAPABILITY

Optimize Healthcare Payer Reach and Acquisition

BEST PRACTICES

To orchestrate the correct messages and channels in each
lifecycle stage build automations and audience segmentation
activities
To build automations and segment audiences understand
what data you have and what data you need to gather to enrich
encounters and segmentation
Implement a dynamic system that can move customers
through the current lifecycle stages and into new stages
Coordinate channels Use personalization to engage customers
at each stage of the lifecycle
To create experiences that are lifecycledriven build customer
capability

Marketing Vision and Value Proposition
Identify customer benefits and link them to mechanisms for
Create a vision for how your brand delivers on the promise and
how the product or service delivers value
value to customers Articulate the unique benefits of your
Map the basis for differentiation based on what drives target
brand product or service through marketing
market customers needs and desires Identify brand strengths
and key areas of differentiation
Write the value proposition Treat a value proposition like an
elevator pitch for the product or service
Ensure that the value proposition is based on what potential
customers value not on what you think they value

Partner Relationship Management PRM

Define goals and measurements for your partner program
Identify manage and enable suitable partners to sell a defined Understand the market opportunity based on research and
set of products and services to specific customers on behalf of
trusted data
the company
Set goals aligned to your companys business objectives
Set goals for partners according to their maturity as a partner
Be realistic about forecasted sales growth especially for new
partners
Establish behaviorfocused leading metrics such as number
of deals registered and resultsfocused lagging metrics such
as attrition percent
Develop a reporting plan and dashboards analyzing the health

of your PRM program and partner engagement

Define interaction model with partners for lead management
and generation
Establish feedback loop to understand market needs
Enable partners to advocate for your products and answer
customer questions effectively

Customer Guide for Healthcare Payers

Optimize Healthcare Payer Reach and Acquisition

CAPABILITY

BEST PRACTICES

Account Segmentation
Align segmentation to the organizations business goals
Identify and prioritize groups of customers with similar needs Classify accounts by segment
growth potential complexity or other attributes Align the
Consider how segment attribute information is structured
resources that match them
captured and maintained to support account segmentation
Consider how to handle complex segmentation scenarios in
a consistent way across the business
Consider which of the other business capabilities are influenced
by or supported through account segmentation
Consider the sales team structure and match it to the account
segments and tiers
Consider how partners can add value across segments and
what insights can help them do so
Analyze the resources required to deliver the best servicing
approach
Consider the geography of the accounts
Allocate resources to the segments and tiers
Account Segmentation Approach
Define prioritize and combine segment attributes Group
accounts to support business goals

Align segmentation to the organizations wider business goals
Ask sales marketing service the business unit and other key
leaders to define the overarching business goals
Let sales leaders derive objectives that support business goals
Ask sales leaders and sales operations to identify key attributes
that help profile accounts Use qualitative and quantitative
data such as industry number of employees and future
revenue potential
Combine multiple attributes for a wellrounded segmentation
approach

Customer Segmentation for Marketing
Establish marketing goals for this segment
Divide shoppers and prospects into logical segments to inform Determine audience behavioral goals in context For example
customer experience strategy
what a consumer can reasonably be expected to do in a specific
circumstance Good sources of behavioral data include
Conversions
Specific site section visitors
Top funnel visitors
Users who were exposed to or clicked digital media
High value visitors
Visitor churn
Formulate hypotheses about your audience that you want to
validate with segment creation and analysis

Customer Guide for Healthcare Payers

CAPABILITY

Optimize Healthcare Payer Reach and Acquisition

BEST PRACTICES

Before creating a segment review existing segments to
determine if theyre a potential match
Create audience segments using multiple criteria including
behavior preferences demographics and lifestyle Prioritize
firstparty data over secondparty data and secondparty data
over thirdparty data
Name segments according to a standard pattern Include
contextual words or abbreviations to make it easier to find and
share segments with others
Use recency and frequency information to modify your
segment definitions if possible
Create an intuitive segment taxonomy For example a
classification schema that uses a hierarchy or folders
Examine the size of the audience Consider whether it requires
immediate nurturing to grow
Determine if the segment is incremental to your existing or
target audience If not modify criteria for inclusion in the
segment
Document and share the why how overlap details and
persona of the segment you created

Customer Segmentation for Service
Segment customers by demographics behavior geography
Align corporate customer segmentation models to determine
benefit customer journey or other relevant qualities
service support and channel strategies
Create customer profiles that provide useful information and
context for each customer
Tailor customer support experiences based on customer
segment For example target specific customer segments for
more or less personalized service based on spend or value
Address concerns before they arise and make every customer
service interaction special
Next Best Action

Use AI to predict detect profile and classify cases across the

Provide proactive recommendations to service agents on what
customer service organization
to do next based on customer and industry data and builtin Provide productivity gains by automatically relating

business logic Use AI to predict detect profile and classify

multichannel correspondence and resolution notes to the
cases across the customer service organization
case lifecycle

Use customer context and AI to recommend knowledge

Recommend articles based on relevance to the request theyre
working on
Recommend Knowledge
Enable suggested articles so that when a new case is saved
Resolve cases more quickly by surfacing recommended
the search engine automatically looks for articles that have
knowledge articles based on key service request characteristics
keywords in common with the adminselected case fields

Customer Guide for Healthcare Payers

CAPABILITY

Optimize Healthcare Payer Reach and Acquisition

BEST PRACTICES

Site Recommendations
Enable suggested articles so that when a new case is saved
Place personalized product recommendations throughout the
the search engine automatically looks for articles that have
customer experience to drive conversion and higher perunit
keywords in common with the adminselected case fields
transaction and average order value
Define business goals for your recommendation strategy
Build out locations to deploy recommendations such as
product details page home page category landing page and
campaign pages

Conduct AB testing to identify the optimal strategy for each

location

Deploy monitor and conduct AB tests periodically to ensure

that strategies continue to perform
Audience Activation
List all marketing campaigns and initiatives
Proactively target or suppress defined audiences in support of Identify which audiences to target or suppress
customercentric marketing
To set realistic expectations examine the match rates with the
marketing platforms and partners where the segment is
activated If the estimated size of the matched segment
population is low consider adding or activating more segments
that dont have heavy overlap
Depending on your campaign objectives and category monitor
audience reach and performance daily or weekly
Classify and document each campaign initiative and audience
using metadata descriptors
Keep documents updated to understand overlapping targeting
and audience targeting duplication
Measure the percentage of marketing campaigns and initiatives
that use targeting or suppression
Create target percentages by quarter Include data showing
progress in monthly transformation roadmap reviews
Generate monthly reports for senior marketing and executive
leadership that highlight improvements in key progress
indicators

Help Members Research Compare and Select Health Insurance
Apply experience design principles and testing methods to create an intuitive shopping experience that helps members research doctors
medications benefits and costs Support conversion and retention by providing support at key moments especially when a new member
is stalled in a purchasing journey

Solutions
Beginning
Enable Health Cloud Provider Search

DOWNLOAD

CUSTOMER GUIDE FOR HEALTHCARE PAYERS

SEE ALSO

Platform Enablers API and Data Sources are common across all lifecycle stages and business processes Use platform enablers APIs and

SEE ALSO

BB systems typically rely on these elements

Smart automation like machine learning and AI helps you optimize your use of customer data To enhance your customer relationships

A Business Capability Maturity Assessment arranged by your Success Manager or Account Executive can help you determine which areas

SEE ALSO

SEE ALSO

Improved per member per month revenue PMPM

Data to support process KPI metrics can be pulled from Salesforce reports

CRM Analytics for Healthcare

CDP optional

BC Commerce optional

SEE ALSO

CAPABILITY

BEST PRACTICES

marketing call centers BB commerce and partner relationship

A basic lifecycle consists of awareness acquisition onboarding

CAPABILITY

BEST PRACTICES

Partner Relationship Management PRM

of your PRM program and partner engagement

CAPABILITY

BEST PRACTICES

CAPABILITY

BEST PRACTICES

Use AI to predict detect profile and classify cases across the

business logic Use AI to predict detect profile and classify

Use customer context and AI to recommend knowledge

CAPABILITY

BEST PRACTICES

Conduct AB testing to identify the optimal strategy for each

Deploy monitor and conduct AB tests periodically to ensure