Care Events

Care Events Overview

Care Events are a member-level configuration tool that lets you apply targeted rules to how a member's claims are handled by Yuzu’s adjudicators.

Specifically, Care Events allow you to:

• Pend claims for a member, optionally scoped to a service date range and/or a specific billing provider

• Set a network tier for a member, also optionally scoped to a service date range and/or billing provider

Once created, Care Events surface automatically in the adjudication workspace and the call center, and are archived instead of deleted when finished.

Care Events vs. Cases

If you've used Cases to manage member-level claim handling in the past, Care Events will feel familiar in purpose but different in approach.

Cases are a general-purpose communication and case management tool — they're designed to keep conversations, documents, and claim attachments organized within the Yuzu portal. In the past, Plan Designers have used the Stop Claims Processing Flag to halt claims processing for members with special circumstances (e.g., subrogation, complex medical needs, etc.). But we saw a need among our customers for a more fine-tuned solution, so we created Care Events.

Care Events are purpose-built for claim handling logic specifically. Rather than pausing adjudication of all claims for a member, they apply precise, scoped rules to halt only the claims you need. You can target a specific date range, a specific provider, or both.

This makes them significantly more granular than Cases for adjudication-related workflows, and over time, Care Events will become the primary way to pend claims and manage tier assignments.

When to Use Care Events

Care Events are the right tool when you need to apply specific claim handling logic to a member and when that logic is bounded in some way (by provider, by date, or both).

Use Care Events to pend claims when:

• A member has an ongoing issue that requires claims review before payment, but you don't need to freeze all adjudication indefinitely

• You want to catch claims from a specific provider or within a specific service date window before they process automatically

Use Care Events to set a tier when:

• A provider needs to be considered in-network (or at a specific tier) for a particular member — for example, when a member has established care with an out-of-network provider under special circumstances

How to Use Care Events

Creating a Care Event

1. Navigate to the member's profile in the Yuzu portal.

2. Open the Care Events tab.

3. Select New Care Event and choose the event type: Pend Claims or Set Tier.

4. To Pend Claims:

   1. Service date range: Restrict the Care Event to claims with service dates within this window

   2. Billing provider (optional): Restrict the Care Event to claims from a specific provider name, TIN, and/or NPI

   3. Notes (optional): Add Optional notes to provide context on the Care Event. We highly encourage adding detailed notes to each care event.

      

5. To Set Tier:

   1. Service date range: Restrict the Care Event to claims with service dates within this window

   2. Choose Tier: Choose the benefit tier the claim should be processed under (typically moving from out-of-network to in-network)

   3. Billing provider (optional): Restrict the Care Event to claims from a specific provider name, TIN, and/or NPI

   4. Notes: Add notes to provide context on the Care Event. We highly encourage adding detailed notes to each care event. Please also add your name and date you created the care event.

      

• Save the Care Event. It will become active immediately.

Editing a Care Event

To edit a care event, simply click on the “Edit” button in the top-right corner of the care event box.

Archiving a Care Event

To archive a care event, click on the “Edit” button in the top right corner of the care event box. Then, click “Archive.” This will add the Care Event to our internal repository.