Cases: Creating, Assigning, and Monitoring

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When to create a case?

Create a case for any situation that requires additional context or clarification. Most cases are created after a service has been rendered

Examples include:

• Maternity cases: capture the following, as these answers help add context to the overall cost of the pregnancy:

  • Estimated Due Date (EDD)

  • Type of delivery: Vaginal, C-section, VBAC

  • Place of delivery: Hospital, Birthing Center, Home

• Surgical cases: begin the medical record retrieval process as soon as possible, since any case exceeding $10,000 must be submitted to MedWatch for a medical necessity review.

• Any accident or injury: we will also need to kick off an Accident Investigation Form before processing anything.

• Requests for exceptions to standard processing procedures

• Claim adjudication changes: appeals, reprocessing, COB changes, etc. Assign to the appropriate Plan Designer Yuzu Pool (e.g., Yuzu Claims – Plan Designer X – Yuzu).

• NSA / Open Negotiations

How to create a case?

There are three ways to create a case:

1. Go to the member’s profile → case tab → create case.

2. Go to the group's Cases tab on the side bar → select + New in the top right corner

3. While viewing a claim, select Cases on the tab bar and follow the same flow as above

Case Titles

Keep case titles short, descriptive, and informative. Titles can include diagnosis, signs/symptoms related to the claims, dispute number, etc.

Examples:

• Maternity – EDD 8/15/26, C-section at Memorial Hospital

• Knee arthroscopy – MedWatch review pending ($12,500)

• MVA 4/22/26 – Accident Investigation Form sent

• Appeal – Claim #12345, denied for medical necessity

• COB update – Primary now Aetna, eff. 1/1/26

• Reprocess Claim #67890 – Corrected CPT from provider

• NSA Dispute #NSA-2026-0847 – ER services, out-of-network

Assigning and working in cases

Assign cases appropriately so the right team (Pool) can work on them.

• Assign the case to the individual who has the action item or is actively working on something.

• Be as specific as possible and provide all necessary context in the case about what you need the assigned individual to review. For example: assign to Sara Gonzalez within the "Yuzu Cash Pay Team - Yuzu" Pool, ask for help pricing, and place the case in Todo status.

• @name the person you are asking to do something or who you need help from.

• All communications should be professional and factual — no opinions.

• Always attach the relevant letter and note the delivery details in the log. For example: "Sent to MedWatch on May 1st, 2026."

Accessing and monitoring a case

On the left-hand navigation panel, select Claims under the Data section. This opens a list of members with their claim details, including status, plan pays, OOP amounts, provider, and date of service. From the claim list, click on the member you would like to review.

Once inside a member's case, you can view all activity in the case feed. This log shows status changes and comments, along with the timestamp and user who made each update.

*There are no automatic email notifications for new messages. You must log into the portal and check each member's case for updates.

Closing a case

Yuzu manages all communications directly with providers throughout the case process. Once the case has been successfully processed, Yuzu will mark it as Resolved. This status update confirms the case is complete and no further action is needed.

If the case is upheld, a letter of communication between Yuzu and the provider will be created.

Until a case is marked Resolved, continue to manually check the portal regularly for any updates or new communications.