CSM to CE&E Escalation Process

1. Overview Process

This SOP standardizes how Customer Success Managers (CSMs) escalate issues, manage tickets, and coordinate with Customer Education & Enrollment (CE&E) Team. It applies to all CSMs across all pods and covers escalation creation, ownership of admin vs. employee questions, communication standards, and ticket hygiene.

The goal is that when an employer brings an issue to the CSM that needs CE&E team’s attention, the CSM will create an Escalation ticket, follow the ticket, and track the progress to the resolution.

Guiding principle: “If it’s not in HubSpot, it didn’t happen.” All client-facing communication, escalations, and notes must live in HubSpot — not Teams.

1.1 Prior to creating an Escalation Ticket

Before creating a new escalation, search HubSpot for an existing ticket on the same issue to avoid duplicates.
If no ticket exists, create a new escalation ticket in HubSpot under the employee HS profile.
If you already know the resolution and know research or digging is needed from CE&E you can leave a note on the person’s profile and tag a manager.

2. Escalation Types

Some escalation types are generated automatically by the platform and should never be selected manually. Others are intended for CSMs to choose from when they are creating a new ticket. Selecting the wrong type — especially mislabeling a Medicare issue or stuffing a complex problem into Missing Premium — causes round-robin misrouting and slows resolution.

2.1 Type Selection & Description

Escalation Type	Source	When to Use
Mismatch	Platform-generated	Do NOT manually select. These open automatically from platform activity and close in the platform.
Dual Enrollment	Platform-generated	Do NOT manually select. Generated by the platform when duplicate coverage is detected.
Unexpected Credit	Platform-generated	Do NOT manually select. Generated by the platform.
Medicare Mismatch	Platform-generated	Do NOT manually select. Starts and closes in the platform.
Missing Premium	Manual	Use ONLY when a premium is truly missing and just needs a one-time payment. This type round-robins to Tier 1 — mislabeling complex issues here misroutes them. For complex situations, use Other.
AutoPay	Manual	Auto-pay set-up requests. Note: auto-pay may not pull until later in the depending on the carrier; check before escalating.
Medicare Missing Premium	Manual	Paused — see Section 5. Document in the shared audit spreadsheet rather than creating an escalation.
Medicare Auto Pay	Manual	Manual creation for Medicare auto-pay set-up issues. DO NOT use unless Medicare SME confirms this is correct type
Reinstatement	Manual (usually)	Typically manual. Can come from the platform in some cases.
Coverage Change Request	Manual	Use ONLY when escalating an existing coverage change request issue. Do NOT use this type to initiate a CCR — those must start in the platform.
Access to Care	Manual	Member cannot access a needed service (doctor visit, prescription fill, etc.) or is at imminent risk of that. Always Urgent!
Care Navigation	Manual	Provider no longer in network, continuity-of-care requests, network exception requests, and similar provider-side navigation.
Claims Denial / Appeal	Manual	Carrier has denied a claim. Help the member with the appeal process and document the path.
Claims / EOB Question	Manual	Member has an EOB they do not understand (deductible questions, why a service wasn’t covered, etc.). Investigate against the SBC.
Other	Manual	Catch-all. Routes to the pod manager for reassignment. Use when an issue spans multiple categories or doesn’t fit cleanly — include a clear description so the manager can route correctly.

2.2 Type Selection Rules

Label Medicare issues as Medicare. If a member has both Medicare and IFP coverage and one is unpaid, the escalation type must reflect the affected coverage. A Medicare issue mislabeled as Missing Premium will round-robin to the wrong queue and may be closed prematurely if a different policy shows paid.
Never manually create platform-sourced types. Mismatch, Dual Enrollment, Unexpected Credit, and Medicare Mismatch start and close in the platform. Creating these manually clutters the queue.
Use Other when the issue spans multiple categories. If a single member issue includes (for example) an effective date correction and a payment remap, create one Other ticket with a clear description rather than splitting it into multiple tickets. Do not create more than one ticket for the same issue on the same member.
One ticket per member. Each employee issue must be its own ticket so it can be assigned to the right specialist and tracked independently.
Missing Premium is for true missing premium only. The round-robin sends this type to tier 1. If the situation is complex (e.g., a one-time payment was initiated but didn’t clear, employee getting notices), use Other or Access to Care so the manager can read the description and route appropriately.

2.3 Required Detail in the Description

Whichever type you choose, the description must give the receiving teammate enough context to act. Include:

Employee and employer name
The specific issue, in as much detail as you have
Research you have already done (benefitbay's payment page, existing HubSpot notes/communication, any documentation provided, etc)
Urgency level and the reason it meets that level
Any prior ticket references for context (do not reopen the previously closed ticket)

3. Urgent vs. Non-Urgent

Over-flagging Urgent slows triage of true emergencies. Mark a ticket Urgent only when it meets the criteria below. Most escalations are Medium.

3.1 Updated Priority Matrix

Priority	Follow-up Window	When to Use — Updated Criteria
Urgent	Same day; follow up within 1–2 business days if no visible action	Reserved for true access-to-care impact or financial exposure that cannot wait. Examples: • Employee or dependent cannot access a doctor, fill a prescription, or use coverage in the next few days • Unexpected credit or charge actively affecting the member • Coverage termination due to non-payment • Data error blocking a service the member needs immediately (e.g., DOB mismatch when an appointment is imminent)
High	Follow up after 3 business days if no visible action	Important but not actively blocking care. Should be resolved within the week (e.g., auto-pay setup where a one-time payment has already cleared, time-sensitive QLE prep before a deadline).
Medium	Follow up after 5 business days of inactivity – typically resolved in 3 weeks	Standard follow-ups, research items, and mismatches that do not affect care. Most escalations live here. Examples: • Name corrections and address updates (carrier turnaround is typically 5–7 business days) • Payment mismatches without access-to-care impact • Claims/EOB questions, network exceptions, continuity of care

3.2 How to Decide Urgency

Ask: “If this isn’t resolved today, does the member lose access to care or take a financial hit?” If yes, it’s Urgent. If the resolution depends on standard carrier turnaround (5–7 business days for name changes, address corrections, ID issues) and the member doesn’t need to use coverage in that window, it is not Urgent — even if the member is unhappy about it.

3.3 Follow-Up Cadence

Before following up on a ticket, check both the ticket and the employee’s HubSpot profile for Notes. At times, notes auto-associate to the agent contact instead of the employee, so a ticket that looks blank may have activity on the profile.

Urgent: if there is no visible action within 1–2 business days, tag the assigned manager in the ticket and ask for an update.
High: if the ticket has been stagnant for 3 business days with no notes, tag the assigned manager in the ticket and ask for an update.
Medium: if the ticket has been stagnant for 5 business days with no notes, tag the assigned manager in the ticket and ask for an update.
Respect carrier turnaround. If a screenshot or note shows the carrier was contacted 1–3 days ago and the carrier’s stated turnaround is 5–7 business days, do not follow up yet.
Tickets that have been started should not stay in “New.” They should be moved to In Process, Waiting on Internal Party, Waiting on External Party, or Resolution — with a note documenting the action. If a ticket is sitting in New with no activity, that is a reasonable point to tag the manager.

3.4 Realistic Resolution Targets

Non-urgent escalations: closed within ~3 weeks. Mismatches and back-and-forth claims work can take longer.
Urgent escalations: same-day acknowledgement, with movement within 1–2 business days.
Communication should be provided to employers when setting expectations — especially when an employee submits a request late and is pushing for a same-day fix.

4. Minor Requests — When Not to Create a Ticket

Not every action needs an escalation ticket. If we already know the resolution and just need someone to take a quick action step, create a note on the employee’s HubSpot profile and tag the responsible teammate (e.g., tag the transactions owner on a remap, the QLE owner on an SEP close-out, etc). Reserve escalation tickets for issues that need research, decision-making, or carrier interaction.

If unsure whether it should be a ticket or a note, default to a note-tagging the manager. The manager can convert it into a ticket if research is actually needed.

6. QLE and SEP Hand-offs

This section complements the existing QLE guidance and reflects the manager check-in confirmation about how CSMs should flag missed steps.

When a CSM notices an SEP that wasn’t closed, a prior plan that wasn’t end-dated, or a waiver that wasn’t end-dated after a coverage change, leave a note on the employee’s HubSpot profile.
Tag the QLE owner and the QLE manager in the note. Be specific: name the member, the missed step, and what action step you took (or what step needs to be taken)
Do NOT create an escalation ticket for these — they are direct hand-offs to the responsible person. The note on the profile creates the audit trail.
Continue to advocate with employers and employees that coverage change requests be submitted by the 15th of the month for next-month effective dates. SEPs are open through the 20th to allow shopping and document collection. Submissions after the 14th–15th may push effective dates to the following month, except for state-specific allowances or genuine emergencies.

7. Communication Reminders

HubSpot is the system of record. “If it’s not in HubSpot, it didn’t happen.” Notes, follow-ups, and tags belong on the ticket or the profile, not in Teams.
Click Follow on every escalation you create so you receive notifications on updates.
When following up, check both the ticket and the employee profile before tagging the manager — the activity may exist but be associated with a different contact.
It is reasonable to follow up. It is not reasonable to follow up on day 2 when the carrier’s stated turnaround is 5–7 business days. Use Teams only for casual nudges only when the issue is genuinely time-sensitive and HubSpot escalation is already in motion.