AI for Complaints, Appeals, and Grievances

Every health plan strives for operational excellence and member trust. However, as STAR ratings grow more competitive and CMS scrutiny intensifies, one area emerges as a critical lever for improvement: Complaints, Appeals, and Grievances (CAG).

Recently, even high-performing plans have seen dips in ratings. In 2025, only 7 Medicare Advantage plans earned a 5-star rating, down from 38 the year prior. The causes are often not about effort or intent but visibility, scalability, and complexity.

The CAG Opportunity Behind STAR Success

While teams focus on high-priority initiatives, including networks, benefits, and engagement, CAG operations quietly shape member experience and compliance outcomes.

• Member complaints are rising across all channels
• Manual processes struggle to meet turnaround times
• Audit preparedness relies on scattered workflows
• Compliance risks add up silently, affecting ratings and reputation

The perspective paper explores how forward-looking health plans are transforming CAG operations by using automation and AI to bring clarity, consistency, and control to complex workflows.

Download the Perspective Paper to Learn:

• Where STAR ratings are silently slipping and what CAG has to do with it
• How to modernize CAG operations without disrupting existing systems
• How AI + automation cut through complexity and optimize performance
• How Newgen’s CAG solution, built on an AI-first, low-code platform, simplifies compliance, enhances outcomes, and minimizes administrative burden