Digital. Dynamic. Dependable.
Resolving Every Member and Provider Complaint, Appeal, and Grievance within CMS Deadlines with Confidence
Oversee the full lifecycle of member and provider complaints, appeals, and grievances with CMS-compliant workflows, automated SLA tracking, and content-centric case file management. Meet regulatory deadlines with confidence and significantly reduce manual effort.
“Working with Newgen has been transformational for us. Their Complaints, Appeals, and Grievance solution have boosted our efficiency by 215% and improved our STAR rating by 1.5 points. Newgen’s team was with us in every step of the way, helping us achieve a 3:1 ROI.”
– Vice President of Member Services & Appeals, A Leading Health Plan
NewgenONE AI Agents Purpose-built for Complaints, Appeals and Grievances
Built on the AI-first, low-code NewgenONE platform and protected by the Newgen Agentic Shield, specialised AI agents can sense, reason, and act across your CAG workflows while staying firmly within guardrails for CMS and state regulations and keeping human-in-the-loop.
1. Triage Agent
2. Reasoning Agent
3. Correspondence Agent
4. QA Audit Agent
1. Triage Agent
Purpose-built to accelerate intake and classification
The Triage Agent eliminates one of the biggest bottlenecks in CAG: manual sorting and case setup.
Key capabilities:
- Auto-classifies cases (appeal, grievance, coverage issue, clinical denial, etc.)
- Processes handwritten and scanned documents for classification and extraction
- Identifies case priority and SLA deadlines
- Extracts entities and classifies documents (letters, EOBs, provider notes)
- Retrieves relevant internal SOPs and CMS guidance
By turning first-touch work from minutes into seconds, it reduces routing errors, improves SLA adherence, and ensures every case starts with the proper context.
2. Reasoning Agent
Purpose-built to ensure consistent, clinically sound, policy-aligned case decisions
The Reasoning Agent raises the rigour and consistency of determinations.
Key capabilities:
- Interprets clinical documents and benefit policies together
- Fetches CMS memos, national coverage determinations, and state-specific rules
- Produces case-specific reasoning, recommended determinations, and supporting evidence
- Applies deterministic logic where strict adherence is required
Decision-makers receive clear, evidence-based justifications, reducing variability, avoidable overturns, and compliance risk while improving member trust in outcomes.
3. Correspondence Agent
Purpose-built to generate CMS-compliant letters instantly
Member and provider letters are among the most time-consuming and error-prone steps in CAG process.
Key capabilities:
- Drafts and customizes communications for members, providers, and representatives
- Ensures correct CMS formatting, tone, timelines, and policy language
- Pulls reasoning, case facts, and regulatory citations directly from case history
The Correspondence Agent eliminates manual drafting, speeds up notifications, and ensures every letter is precise, specific, and compliant.
4. QA Audit Agent
Purpose-built to strengthen your compliance posture
Quality and audit teams gain an always-on digital reviewer.
Key capabilities:
- Autonomously executes QA checklists across sampled or targeted cases
- Scores cases and generates audit-ready reports
- Flags potential compliance risks or SLA violations early
- Provides evidence trails and reasoning for every score
This leads to higher STAR performance, improved readiness for CMS and state audits, and greater organisational confidence in CAG quality.
1. Triage Agent
Purpose-built to accelerate intake and classification
The Triage Agent eliminates one of the biggest bottlenecks in CAG: manual sorting and case setup.
Key capabilities:
- Auto-classifies cases (appeal, grievance, coverage issue, clinical denial, etc.)
- Processes handwritten and scanned documents for classification and extraction
- Identifies case priority and SLA deadlines
- Extracts entities and classifies documents (letters, EOBs, provider notes)
- Retrieves relevant internal SOPs and CMS guidance
By turning first-touch work from minutes into seconds, it reduces routing errors, improves SLA adherence, and ensures every case starts with the proper context.
2. Reasoning Agent
Purpose-built to ensure consistent, clinically sound, policy-aligned case decisions
The Reasoning Agent raises the rigour and consistency of determinations.
Key capabilities:
- Interprets clinical documents and benefit policies together
- Fetches CMS memos, national coverage determinations, and state-specific rules
- Produces case-specific reasoning, recommended determinations, and supporting evidence
- Applies deterministic logic where strict adherence is required
Decision-makers receive clear, evidence-based justifications, reducing variability, avoidable overturns, and compliance risk while improving member trust in outcomes.
3. Correspondence Agent
Purpose-built to generate CMS-compliant letters instantly
Member and provider letters are among the most time-consuming and error-prone steps in CAG process.
Key capabilities:
- Drafts and customizes communications for members, providers, and representatives
- Ensures correct CMS formatting, tone, timelines, and policy language
- Pulls reasoning, case facts, and regulatory citations directly from case history
The Correspondence Agent eliminates manual drafting, speeds up notifications, and ensures every letter is precise, specific, and compliant.
4. QA Audit Agent
Purpose-built to strengthen your compliance posture
Quality and audit teams gain an always-on digital reviewer.
Key capabilities:
- Autonomously executes QA checklists across sampled or targeted cases
- Scores cases and generates audit-ready reports
- Flags potential compliance risks or SLA violations early
- Provides evidence trails and reasoning for every score
This leads to higher STAR performance, improved readiness for CMS and state audits, and greater organisational confidence in CAG quality.
NewgenONE AI Agents
Purpose-built for Complaints, Appeals and Grievances
Complaints, Appeals & Grievances Solution: Buy All-in-one Pack or Choose an Individual Solution
Newgen’s CAG Solution for Fast-tracked NCQA Accreditation
Fast-track your accreditation process while minimizing manual efforts, ensuring audit-readiness, and improving member satisfaction.
Learn What NewgenONE Complaints, Appeals, and Grievances Solution Can Do for You
Efficient Case Management
Detect and flag duplicates to prevent fraud and speed up medical and pharmacy resolutions. Automate case allocation to optimize bandwidth. Manage escalations, prioritize cases, and extend case timelines as necessary. Ensure robust integration with document management capabilities to streamline content-centric workflows, improve accuracy, and fast-track claims and reviews.
Unified Information Capture and Processing
Consolidate data capture from multiple sources for efficient case processing. Fetch eligibility details of members and providers from the core system in one place. Leverage GenAI to extract critical data, classify records, and generate instant summaries from documents (medical records and EOBs) for informed decision-making
Automated Communications, Audit Documentation, and Packet Generation
Generate automated correspondences, including acknowledgment and resolution letters, to ensure adherence to regulatory mandates. Compile case summaries with relevant clinical, medication, formulary, and benefit data and artifacts. Create downloadable case packets for internal/external audits and CMS compliance. Customize reports to meet CMS requirements and gain insightful analytics for informed decision-making.
360-degree Case Visibility, Decision Support, and Integration
Access a comprehensive dashboard to manage cases and get periodic status reports and updates. Leverage AI/ML algorithms to support decision-making and enhance efficiency. Integrate pharmacist and medical director clinical/MD reviews into the process for accurate case assessment. Ensure robust integrations with external portals for smooth data exchange. Ensure data accuracy and compliance through intelligent validation mechanisms.
Efficient Case Management
Detect and flag duplicates to prevent fraud and speed up medical and pharmacy resolutions. Automate case allocation to optimize bandwidth. Manage escalations, prioritize cases, and extend case timelines as necessary. Ensure robust integration with document management capabilities to streamline content-centric workflows, improve accuracy, and fast-track claims and reviews.
Unified Information Capture and Processing
Consolidate data capture from multiple sources for efficient case processing. Fetch eligibility details of members and providers from the core system in one place. Leverage GenAI to extract critical data, classify records, and generate instant summaries from documents (medical records and EOBs) for informed decision-making
Automated Communications, Audit Documentation, and Packet Generation
Generate automated correspondences, including acknowledgment and resolution letters, to ensure adherence to regulatory mandates. Compile case summaries with relevant clinical, medication, formulary, and benefit data and artifacts. Create downloadable case packets for internal/external audits and CMS compliance. Customize reports to meet CMS requirements and gain insightful analytics for informed decision-making.
360-degree Case Visibility, Decision Support, and Integration
Access a comprehensive dashboard to manage cases and get periodic status reports and updates. Leverage AI/ML algorithms to support decision-making and enhance efficiency. Integrate pharmacist and medical director clinical/MD reviews into the process for accurate case assessment. Ensure robust integrations with external portals for smooth data exchange. Ensure data accuracy and compliance through intelligent validation mechanisms.
Explore Other Solutions for the Payer-Member Journey
Member Portal
Empower members with instant access to information, enhancing convenience and engagement
Member Enrollment
A proven one-size-fits-all product enrollment framework, designed to fit the plan’s specific rules
Premium Billing
Simplify end-to-end billing process while enhancing precision and overall accuracy
Sales and Retention
Boost sales and retention with an AI-driven, automated system while gaining real-time insights into the process
Medicare Mobile Enrollment App
Efficiently manage your enrollment processes, eliminate paper-based transactions, and capture member information on-the-go
See How Much You Can Save with Newgen’s CAG Suite
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