All use cases

Engage / Lifecycle

Health-benefits utilization nudge coach

The member is already paying for a telehealth visit, a wellness allowance, and a screening they're due — and using none of them. The agent gets them to spend what they own.

Get aheadBehavioral triggerTime-based triggerIn-appPushChatInsuranceHealth & TelehealthWellness (B2C apps)

What it does

Most members never use the benefits inside their plan. A free telehealth consultation goes unbooked, a wellness or fitness allowance expires untouched, an annual screening lapses past its due date. For the member it is value left on the table; for the insurer or benefits provider it is the metric the whole model depends on, because a plan that is paid for and unused is a member who sees no reason to renew and a population whose risk goes unmanaged. The agent runs an ongoing utilization conversation: it notices what a member is entitled to and hasn't used, and nudges them to use it, with the booking or the next step right there in the thread. It coaches members toward the benefit; it does not give medical advice, and any clinical question or concerning symptom is routed to a clinician.

How it works

  1. 1
    Trigger. a utilization gap surfaces — an included benefit unused with the plan period running down, a recommended screening past its due date, or a wellness allowance about to expire.
  2. 2
    Decision. the agent reads the member's entitlements, what they have already used, their channel preference and consent, and decides whether there is a genuinely useful, eligible move to suggest now; a judge gates the message so a member who is already up to date hears nothing.
  3. 3
    Action. a short, specific nudge on the member's preferred surface — "your plan includes a telehealth visit you haven't used; want me to find a time?" — with a one-tap path into booking or the next step, framed as value they already own rather than an upsell.
  4. 4
    Follow-through. a completed booking or claimed benefit writes back to the member's record and resets the cadence; a pending nudge is cancelled the moment the member acts; any clinical question, symptom, or eligibility dispute hands off to a clinician or a benefits specialist with full context.
Example
AgentQuick one — your plan includes an annual wellness screening, and it looks like this year's is still open with about six weeks left in your benefit period. It's fully covered, no cost to you. Want me to pull up a few appointment times?
MemberOh, I forgot that was included. Is there anything I need to do to prepare?
AgentNothing beyond booking it — I'll send the slots now and a reminder closer to the day. If you've got a specific health question for the screening, I'll make sure it goes to your care team rather than answering it myself.

Configuration

How the agent is wired for this use case.

Triggera utilization-gap event — benefit_unused near period end, screening_overdue, or allowance_expiring — from the benefits-administration or member-engagement platform.
Tools & actions
  • Benefits-administration system · read the member's entitlements, what's been used, eligibility, and the benefit-period dates
  • Member / care record · read prior outreach and usage history; write back the booking or claimed benefit and reset cadence
  • Scheduling system · surface eligible appointment slots and hand the member into booking the covered visit or screening
  • Clinician / benefits-specialist queue · route any clinical question, symptom, or eligibility dispute to the right human with context
  • Messaging channel · deliver the utilization nudge and the booking step on the member's preferred surface
Autonomynudge selection, timing, and the booking step run unattended under judge gating, quiet hours, and frequency caps. The agent gives NO medical advice, diagnosis, or dosage guidance under a clinical-safety policy class — it nudges toward an entitled benefit and hands off booking; any clinical content is detect-and-escalate to a clinician.
Channelsin-app · push · chat
Escalationa clinical question or symptom, a contested eligibility or coverage decision, or a complaint hands off to a clinician or benefits specialist with the member's context attached.

What you need

The inputs this use case runs on. Your channels stay yours; the agent supplies the judgment.

Signals

entitlement and utilization state (which benefits are included, used, and unused), screening-due and overdue dates, allowance-expiry windows, member responses

Data

member plan and eligibility, benefits-usage history, channel preference and consent, quiet hours, persistent memory of prior utilization nudges

Guardrails

the agent nudges toward entitled benefits only — no medical advice, diagnosis, or dosage; clinical questions and symptoms detected and escalated to a clinician; eligibility framed from plan data, with disputes routed to a specialist; judge gating on every unprompted message; consent, quiet hours, and frequency caps; stale-nudge cancellation once the member acts; the provider keeps owning the send channels

Metrics it moves

  • benefits-utilizationup: included benefits that would expire unused convert into booked visits, screenings, and claimed allowances
  • adherenceup: due screenings and recommended care get completed on time instead of lapsing past their date
  • churndown: members who use what they pay for see the value of the plan and are far likelier to renew

Related use cases

Engage / Lifecycle

Proactive health-coach companion

the program-adherence companion, distinct from nudging unused plan entitlements

Upsell & Cross-sell

Loyalty-program engagement and reward nudges

the same stranded-value instinct on points and tiers rather than health benefits

Prevent / Care

Post-visit aftercare and coverage outreach

coverage and forms outreach around a completed visit

See it on your own customer journey

Bring one drop-off, one churn cliff, or one silent segment. We will show you what a proactive agent with memory and judgment does with it.

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