Appeals and Grievances

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

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 Appeals and Grievances Process Automation Software - Appeals and Grievances

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.

Appeals and Grievances

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
Appeals and Grievances

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

Solutions for Healthcare Payers

Medicare Enrollment

Transform your medicare enrollment on mobile to empower your...

Appeals and Grievances

Effectively respond to members' complaints, appeals and...

Provider Contracting

Govern every step of contract lifecycle and accomplish a...

Success Stories

Improved adherence to due dates by 50% - Appeals and Grievances
Improved adherence to due dates by 50%
Leading health plan automates appeals and grievances process to mitigate bottlenecks, expedite resolution time, and...
Enabled branchless and paperless onboarding - Appeals and Grievances
Enabled branchless and paperless onboarding
Health plan, with expertise in government-sponsored healthcare, digitizes member enrollment process to enable remote and...
Reduced provider review and approval time by 40% - Appeals and Grievances
Reduced provider review and approval time by 40%
US-based health plan streamlines provider contracting process to optimize costs, increase efficiency, and ensure data...

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