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Extending Intelligent Orchestration to Appeals Lifecycle, from Intake to Decision with CMS-compliant Governance
Automate the full appeals lifecycle from intake to decision with CMS-compliant routing, intelligent case review, and governed workflows. Deliver timely, accurate appeals processing with full audit trails and regulatory transparency.
“Newgen’s Appeals Solution has simplified our entire processes, improved accuracy, and strengthened compliance, helping us achieve new levels of efficiency.”
– Vice President of Member Services & Appeals, A Leading Health Plan
Built for Payers. Designed for Members
Leverage our Complaints, Appeals, & Grievances Suite to build trust with a member-first approach.
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 efficiency. Fetch eligibility details of members and providers in one place. Leverage GenAI to extract critical data, classify records, and generate instant summaries for informed decision-making.
Automated Communications, Audit Documentation, and Packet Generation
Generate automated correspondences 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.
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.
Smarter Appeals with AI-powered Decision Intelligence
Unlock intelligence with Newgen’s AI-first platform for accurate decision-making, clinical insights, and precise inventory predictions. Identify documents, extract key details, and automatically route every request, appeal, grievance, or dispute, to its correct workflow. Ensure informed, efficient, and compliant actions at every step.
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 efficiency. Fetch eligibility details of members and providers in one place. Leverage GenAI to extract critical data, classify records, and generate instant summaries for informed decision-making.
Automated Communications, Audit Documentation, and Packet Generation
Generate automated correspondences 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.
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.
Smarter Appeals with AI-powered Decision Intelligence
Unlock intelligence with Newgen’s AI-first platform for accurate decision-making, clinical insights, and precise inventory predictions. Identify documents, extract key details, and automatically route every request, appeal, grievance, or dispute, to its correct workflow. Ensure informed, efficient, and compliant actions at every step.
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 Appeals Solution Can Do for You
Unified Intake and Case Management
Capture and process new cases from all intake channels, including web portals, mailrooms, and faxes, into a single, unified system. Support medical cases such as prior authorization denials, medical-necessity appeals, alongside Rx cases – formulary exceptions, redeterminations, step-therapy exceptions, and tiering exception. Integrate across all sources seamlessly to ensure comprehensive case management, improving accuracy and efficiency throughout the appeals process.
Intelligent Automation for Case Processing
Pull eligibility, claim, authorization and formulary details and NCPDP transaction details automatically from the core system to streamline case management. Categorize cases intelligently, detect redundancies, and route cases efficiently with AI-native tools. Predict case types accurately as sufficient details are extracted, ensuring grievances are correctly routed or disputes are triaged for smooth resolution.
Smart Assignment and Collaboration
Assign cases based on coordinator expertise, prioritizing and managing escalations. Ensure collaboration across teams (clinical nurses, pharmacists, medical doctors, and claims admins) with a unified platform for easy case reviews and redirects. Ensure accountability with automated case histories and research tracking, thereby enhancing audit readiness and efficiency.
Advanced Analytics and Oversight
Gain complete visibility with dashboards and reports tailored to operational and compliance needs. Track productivity, identify bottlenecks, and ensure adherence to Part D regulatory requirements. Generate insights for workforce planning, compliance audits, and business intelligence, driving continuous improvement across workflows.
Automated Communications and Notifications
Generate CMS-compliant correspondence automatically, managing letters, faxes, and emails through omnichannel communication. Ensure timely notifications and escalate delays proactively. Automate written and oral communication tracking for improved member and provider engagement across both medical and pharmacy cases.
Quality Assurance and Audit Preparedness
Evaluate work accuracy and coordinator efficiency with advanced QA sampling algorithms. Use detailed checklists and scores to assess performance. Ensure audit readiness with comprehensive case packets and tools to address regulatory requirements including Rx appeal documentation, minimizing risks and improving compliance outcomes.
Unified Intake and Case Management
Capture and process new cases from all intake channels, including web portals, mailrooms, and faxes, into a single, unified system. Support medical cases such as prior authorization denials, medical-necessity appeals, alongside Rx cases – formulary exceptions, redeterminations, step-therapy exceptions, and tiering exception. Integrate across all sources seamlessly to ensure comprehensive case management, improving accuracy and efficiency throughout the appeals process.
Intelligent Automation for Case Processing
Pull eligibility, claim, authorization and formulary details and NCPDP transaction details automatically from the core system to streamline case management. Categorize cases intelligently, detect redundancies, and route cases efficiently with AI-native tools. Predict case types accurately as sufficient details are extracted, ensuring grievances are correctly routed or disputes are triaged for smooth resolution.
Smart Assignment and Collaboration
Assign cases based on coordinator expertise, prioritizing and managing escalations. Ensure collaboration across teams (clinical nurses, pharmacists, medical doctors, and claims admins) with a unified platform for easy case reviews and redirects. Ensure accountability with automated case histories and research tracking, thereby enhancing audit readiness and efficiency.
Advanced Analytics and Oversight
Gain complete visibility with dashboards and reports tailored to operational and compliance needs. Track productivity, identify bottlenecks, and ensure adherence to Part D regulatory requirements. Generate insights for workforce planning, compliance audits, and business intelligence, driving continuous improvement across workflows.
Automated Communications and Notifications
Generate CMS-compliant correspondence automatically, managing letters, faxes, and emails through omnichannel communication. Ensure timely notifications and escalate delays proactively. Automate written and oral communication tracking for improved member and provider engagement across both medical and pharmacy cases.
Quality Assurance and Audit Preparedness
Evaluate work accuracy and coordinator efficiency with advanced QA sampling algorithms. Use detailed checklists and scores to assess performance. Ensure audit readiness with comprehensive case packets and tools to address regulatory requirements including Rx appeal documentation, minimizing risks and improving compliance outcomes.
Newgen’s QIO Fast Track Appeals Solution
Ensure you never miss a QIO deadline, stay compliant, safeguard member rights, and build lasting trust.
Explore Other Solutions for the Payer-Member Journey
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