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Coverage and claim questions are answered against the member's actual plan configuration, not a generic FAQ.
Member Self-Service & EngagementMember Engagement Platform:
Member Engagement Platform:
Translating Complex Policies into Clear Benefits
HealthOS Member is the member engagement workspace within HealthOS. It lets your members check benefits, claims, pharmacy, deductibles, and care gaps in everyday language, with answers drawn directly from the same live data as HealthOS CAPS. When a question needs a person, it hands off to NOVA, HealthAxis' omnichannel AI contact center, with operational context attached.
HITRUSTSOC 2 Type IICMSHL7 FHIR
My ClaimsBenefitsPharmacyDeductible
Deductible Met62%
Open Claims2
Care Gaps1
Claim CLM-4421Paid, $2,480.00
PaidClaim CLM-4419Coordination of benefits review
ReviewWellness VisitCovered at 100%, no copay
EligibleSample member view: this is what your members see. Figures are sample data, not customer results.
AIAipass™ resolved 91% of member questions this month directly from each member's plan and claims record. (Sample console data.)
Workspace Overview
What Is HealthOS Member?
HealthOS Member is the workspace where members check benefits, claims, pharmacy, coverage, deductibles, and care gaps in everyday language. It uses the same record as HealthOS CAPS, so answers reflect what is actually being adjudicated in real time.
Same Record as CAPS
Claim status and accumulator balances reflect adjudicated claims in real time, from the same record as CAPS.
Connects to NOVA When Needed
Conversations that need a human hand off to NOVA, HealthAxis' omnichannel AI contact center, with complete chat history and member data intact.
Platform Foundation
Self-Service That's Only as Good as the Data Behind It
Portals typically only show a copy of the data. HealthOS Member shows members what is live right now.
Audit Log on Every Member Interaction
Every member interaction is logged, supporting HITRUST and SOC 2 Type II obligations by default.
One Shared Record With CAPS
Claims, benefits, and accumulator data match the live record used across HealthOS, including member data that starts in HealthOS Enrollment. See why member data errors start in enrollment files.
Aipass™ Embedded Intelligence
Aipass™, the embedded intelligence layer running across HealthOS, generates plain-language explanations and proactive care gap nudges from each member's actual record.
Where Your Plan Team and Your Members Each See the Product
What your members see: a self-service view where they ask questions in their own words and get answers about their own plan, claims, and balances, which improves member satisfaction.
What your plan team sees: how many questions were self-resolved and how many went to NOVA, as shown in the Benefits & Coverage console, and an audit log of every member interaction.
Inside Member
Five Modules. Everything a Member Needs to Self-Serve
HealthOS Member has five modules. Together, they serve as engagement solutions for the questions members ask about benefits, claims, pharmacy, deductibles, and care gaps.
Pick one to see what your members see. Read how health plans scale member services.
Benefits & Coverage
Members ask about coverage in their own words and get answers based on their plan documents and benefit configuration.
Plan-Specific ExplanationsCoverage LookupPrior Authorization (PA) StatusMulti-Language
Questions Answered This Month18,240
Self-Resolved91%
Escalated to NOVA9%
“Is this MRI covered?”Answered from plan benefit config
Resolved“Why was this denied?”Explained with adjudication reason
Resolved“Can I get a second opinion?”Escalated to NOVA
EscalatedClaims & EOB
Members see claim status and the explanation of benefits (EOB) for each claim, including plain-English denial explanations and one-click appeal intake.
Real-Time StatusPlain-Language EOBDenial ClarityAppeal Support
Claims Viewed MTD24,410
Avg Time to ViewSame-day
Appeals Initiated312
CLM-4421Paid, $2,480.00
PaidCLM-4419Coordination of benefits review
ReviewCLM-4402Denial explained, appeal started
AppealingPharmacy & Formulary
Members check whether a drug is covered, its tier and copay, and whether it needs prior authorization. A formulary is the plan's list of covered drugs.
Formulary LookupEstimated CostPA Requirement FlagsRefill Reminders
Lookups MTD9,140
Avg Est. Accuracy96%
PA Flags Raised218
Metformin 500mgTier 1, $0 copay
CoveredHumiraRequires prior authorization
PA NeededLisinopril 10mgRefill due in 5 days
ReminderDeductible & Accumulators
Members see how much of their deductible and out-of-pocket maximum they have met. Accumulators are the running totals of those amounts, and they update when a claim adjudicates in CAPS.
Real-Time BalancesFamily vs. IndividualYTD SpendYear-End Estimate
Deductible Met62%
YTD Spend$1,840
Projected Year-End$2,900
Individual Deductible$620 of $1,000 met
In ProgressFamily Out-of-Pocket Max$3,100 of $6,000 met
In ProgressHSA ContributionOn track for year
On TrackCare Gap Nudges
Care gap nudges are the member-facing side of care management software: personalized reminders for open care gaps, such as a diabetic eye exam, built from each member's own record that drive quality measure closure.
Personalized RemindersPreventive ScreeningsWellness AwarenessShared With Plan
Open Care Gaps1
Gaps Closed MTD3,140
Nudges Sent MTD8,920
Diabetic Eye ExamReminder sent
OpenAnnual Wellness VisitScheduled
ScheduledFlu VaccineCompleted
CompleteHow Work Moves
From a Member's Question to an Answer They Trust
Routine queries resolve without a phone call.
- Member Asks
A member asks a question in their own words, such as why their claim was denied.
- Aipass™ Interprets
Aipass™, the embedded intelligence layer in HealthOS, matches the question to the member's plan, claims, and benefit data.
- Answer or Escalate
Most questions resolve immediately. Those needing a real conversation go to NOVA with the full context attached.
- Resolution
The member gets a clear answer, and the interaction updates the same record used by CAPS and Plan.
NOVA Picks Up When a Question Needs a Person
When a member's question needs a real conversation, it moves to NOVA. The conversation arrives with the full context attached, so the member does not need to repeat their story, and the interaction updates the same record CAPS and Plan use. Read how plans handle call volume spikes.
The Intelligence Layer, Inside Member
Health Plan Member Engagement, Grounded in Each Member's Actual Record
Aipass™ translates coverage and claims data out of policy language and proactively surfaces relevant care gaps and benefits without guessing. It works in four stages: Observe, Understand, Predict, Recommend.
Live decision intelligence● Active
“Why was my claim denied?”Explained01 / Review
ClaimCLM-4402
FindingThe service requires prior authorization on this plan variant, and the appeal window is open for 41 days.
Recommended actionExplain this in plain language and offer to start the appeal in the flow.
Confidence 95%
Why Member
What Changes When Self-Service Runs on HealthOS Member
The difference shows up in four places.
Before
- Members used to call customer service to ask about denials.
- Deductible balances used to lag by a day or more.
- Care gap reminders used to be generic.
- Escalations used to make members repeat their story.
After
- Now Aipass™ explains denials and coverage from the adjudication record.
- Now balances update in real time as claims adjudicate in CAPS.
- Now care gap nudges are personalized to each member via digital channels.
- Now NOVA escalations carry full interaction and claim context.
Security & Compliance
Security and Compliance Standards for Member Self-Service
Role-based access control, encryption in transit and at rest, and a complete audit log across every module.
HealthOS Member aligns with HIPAA, HITRUST, SOC 2 Type II, NCQA, HL7 FHIR R4, the CMS Interoperability Rule, and EDI 837, 835, 270 and 271.
HIPAAHITRUSTSOC 2 Type IINCQAHL7 FHIR R4CMS Interoperability RuleEDI 837 · 835 · 270 · 271
FAQ
Frequently Asked Questions
A member engagement platform gives a health plan's members a way to understand their benefits, claims, pharmacy coverage, and balances on their own, and to reach a person when they need one. HealthOS Member does this from the same live record as CAPS.
No. It is an intelligent self-service workspace grounded in each member's plan, claims, and benefit data. Questions needing a real conversation escalate to NOVA with the full context attached.
It reflects the same live record CAPS adjudicates against and updates in real time, eliminating 24-hour batch synchronization delays.
Healthcare member engagement is how a health plan helps members understand and use their coverage, from checking a claim to closing a care gap. In HealthOS Member it is built on each member's own record.
Yes. Aipass™ interprets questions and produces plain-language explanations in supported languages.
Care gap nudges send members personalized reminders for open care gaps from their own record. Ask us how this fits with your care management platform.
The conversation is handed off to NOVA, HealthAxis' omnichannel AI contact center, with the full context attached, so the member does not repeat the story.
HealthOS Member aligns with HIPAA, HITRUST, SOC 2 Type II and CMS requirements, with role-based access control and a complete audit log.
One Console, One Suite
Six Workspaces. One Record.
CAPS, Plan, Provider, Member, Enrollment and Sentinel all read and write to the same core. See the full HealthOS platform.
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