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Appeals & Grievances - Digitize Appeals & Grievances


Digitize Appeals & Grievances

Effectively respond to members' complaints, appeals and grievances while complying with regulatory guidelines.


The Appeals & Grievances process is highly regulated, scrutinized and monitored with severe penalties for non-compliance. Therefore, to resolve standard/expedited cases in a seamless manner while adhering to the state-level and CMS guidelines, you must streamline the process.

We offer you a unified platform that allows timely resolution of appeals & grievances while complying with regulatory guidelines. The smart rules-driven engine prioritizes all transactions for automated routing, ensuring resource optimization, and reduced turnaround times. All decisions, notes, and exceptions are captured within the system for future reference and enterprise-wide audits. Leveraging the platform, you can make your organization future-proof, stay on top of regulations and most importantly, deliver enhanced member satisfaction.

Brochure: Complaints, Appeals and Grievances

Know how you can streamline the end-to-end process and develop that much-needed trust among members as well as regulators.

Automated Duplicate Checker
Identifies duplicate cases in a workflow. If a case already exists, the system flags the duplicate entry so that fraudulent cases are not processed

Audit Packet Generation
Allows case managers to download complete case information as case packets, which can be used for internal and external audits

Previous Cases Detection
Detects similar types of previously closed cases for active cases. And, gives insights to caseworkers so they can offer quick resolutions

Parallel Processing at Investigation
Initiates parallel processing at investigation work-step where tasks are assigned to multiple stakeholders for further processing

Portal/Email/Core System Integration
Creates new cases from custom web portals and emails. Based on multiple criterions, the system is configured to
fetch the member’s/ provider’s eligibility details from the core system

Auto-generated Correspondences
Generates Acknowledgment, AOR and Resolution letters to maintain regulatory compliances for all incoming complaints

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 overall processing times. Witness faster decision making and better member engagement

Secure 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

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 conveniently. Keep business managers apprised of ongoing status of member cases in order to enhance overall visibility in your organization


Newgen's Appeals & Grievances Solution

Watch the video to understand how you can deliver timely resolutions to members' complaints, appeals & grievances, received in any form.


Appeals & Grievances - Optimize Your Appeals & Grievances Process

Optimize Your Appeals & Grievances Process

Read the whitepaper to know about the concrete steps to develop the much-needed trust among your members and providers