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
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