Appeals and Grievances Software
Effectively respond to members' complaints, appeals, and grievances while complying with regulatory guidelinesRequest Demo
Appeals and Grievances Process Automation Software
Resolve members’ appeals and grievances while complying with regulatory guidelines and adhering to state-level and CMS (Center for Medicare and Medicaid Services) guidelines. Optimize resources and reduce turnaround times by leveraging our rule-driven engine to prioritize and route all service requests. Capture all decisions, notes, and exceptions within the system for future reference and audits. Automate your service requests processes to future-proof your organization, stay on top of regulations, and guarantee member satisfaction.
Duplicate and Previous Case Management
- Automatic duplicate checker to flag duplicate entries and avoid fraud
- Previous case detection to identify previously closed cases with similarities to active cases and to offer insights to caseworkers for quick case resolution
Intelligent Case Routing and Assignment
- Parallel processing to assign tasks to multiple stakeholders during the investigation work step
- Intelligent routing with provisions to manage escalations and case exceptions
- Auto-prioritization of standard and expedited cases
Automatic Document Generation
- Automated generation of correspondences, including acknowledgement and resolution letters, and adherence to regulatory compliances
- Automatic preparation of summary documents, including case artefacts and information
360-degree Case Visibility
- Comprehensive dashboard to conveniently manage cases
- Periodic status reports and member case updates to business managers
Audit Documentation and Packet Generation
- Downloadable case packets, containing case information, for internal and external audit use
- Data packages for historical and archived cases for CMS auditing
Unified System for Information Capture
- Integrated system to create new cases from custom web portals and emails
- Automatic fetching of member/provider eligibility details from the core system
Improved adherence to due dates by 50%
Enabled branchless and paperless onboarding
Reduced provider review and approval time by 40%
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