Appeals & Grievances - Digitize Appeals & Grievances


Digitize Appeals & Grievances

Deliver timely resolution of member concerns, when you are swamped with huge volumes of complaints, appeals and grievances


In the era of consumer driven healthcare, you must manage appeals and grievances in a seamless manner to gain a competitive edge. Providing quick and accurate resolutions will enable you to deliver superior member experience, improve star ratings, prevent legal & financial penalties, and most importantly ensure member satisfaction.

We offer you a business configurable process automation and improvement framework that allows timely resolution of appeals & grievances received in any form – email, paper, mail, customer service, web portal, walk-ins, fax, electronic documents etc. The smart rules driven engine prioritizes all transactions for automated routing, ensuring resource optimization, and reduced turnaround times. It guarantees enhanced customer satisfaction, through a robust correspondence management system that automatically initiates appropriate communications at various stages of the process.

Brochure: Complaints, Appeals and Grievances

Automate your day-to-day operations at all levels of administrative hierarchy to deliver timely resolution of cases

Complaint Capturing
Facilitate a single-door entry for member complaints, coming from multiple channels. Integrate directly with various sources, such as Email, portal, and fax, etc.

360-Degree Case View
Get a holistic view of all relevant cases. Access previous case history of members as per need and make well-informed decisions

Load Balancing
Facilitate user or user group to auto-assign cases in all workflows per business role to work in an organized manner

Exception Handling
Utilize pre-configured user tasks and dynamic case management capabilities to take prompt actions for each member complaint. Discard, archive duplicate cases and classify the valid ones for further processing

Auto-generated Letters
Trigger letters, such as acknowledgement, resolution, and appointment of representatives, in the member’s preferred language

Audit Trail Documentation
Collaborate case artefacts and information to prepare case summary documents. Provide data packages for the historical and archived cases for CMS auditing

Reporting Dashboard for CMS Reports
Provide pre-configured dashboard with in-house reports, metrics for operations and reports defined as per CMS guidelines. Get real-time information, complete visibility of all requests data using tabular formats, intuitive graphs and faster searching capabilities

Optimized Processes
Reduce manual hand-offs by automating processes. Minimize scope for unnecessary delays or errors

Better Compliance
Leverage extensive audit features and continually monitor case milestones and resolution timelines

Enhanced Member Engagement 
Access information in real-time and reduce processing time. Witness faster decision making, leading to better member engagement

Secured Information
Save member information in encrypted format. Assign rights-based access for further processing of member cases, and define roles and responsibilities of your business users in a streamlined manner

Easy Integration Capabilities
With capability to comply with global standards and easy integration abilities, leverage and consolidate your existing IT infrastructure

Faster Resolutions
Witness better routing with provisions to manage escalations and case exceptions via workflow and auto-prioritization of standard and expedited cases

Enhanced Visibility
Leverage comprehensive dashboard to manage cases in a seamless manner. Keep business managers apprised of ongoing status of member cases, thereby enhancing overall visibility


Appeals & Grievances - Five Reasons Your Appeals & Grievances Process Hurts

Five Reasons Your Appeals & Grievances Process Hurts

Know how you can address the process challenges and make your members smile


Appeals & Grievances - Optimize Your Complaints, Appeals and Grievances Process

Optimize Your Complaints, Appeals and Grievances Process

Learn about the concrete steps to develop the much-needed trust among your members and providers