“We’ve seen a real difference leveraging Newgen’s Complaints, Appeals, and Grievances solution. The solution has made our workflows smoother and more accurate. The team’s commitment to case integrity and compliance has been vital in helping us achieve operational excellence.”
– 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/flag duplicates to prevent fraud and speed up resolutions. Automate case allocation to optimize bandwidth and manage escalations. Ensure robust integration with document management capabilities for smoother workflows, improved accuracy, and faster claims.
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 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 updates. Leverage AI/ML to augment decision-making efficiency. Integrate clinical/MD reviews for accurate case assessment. Ensure robust integrations with external portals for smooth data exchange.
Learn What Newgen’s Complaints to Medicare (CTM) Solution, from Complaints, Appeals & Grievances Suite, Can Do For You
Unified and Intelligent Case Management
Automate the HPMS flat file intake. Ensure manual case creation for intake coordinators when needed and synchronize updates effortlessly in the CMS module. Integrate complaint histories to ensure root cause analysis and prioritize key cases. Restore member trust by ensuring a unified system for grievance resolution and STARS improvement.
Data-driven Operations
Optimize case handling and minimize inaccuracies with real-time member and provider eligibility data. Flag duplicate cases and utilize insights from similar cases for faster resolutions. Leverage pre-defined business rules to ensure timely SLA and regulatory compliance adherence.
Smart Workflow Management and Resource Allocation
Allocate cases intelligently, manage escalations, and prioritize cases effectively. Assign cases based on the expertise and skillset of coordinators. Simplify multi-issue management by consolidating related concerns into a single comprehensive grid.
Enhanced Collaboration and Oversight
Ensure the supervisor’s review to resolve cases when the QA auditor’s and research coordinator’s suggestions/decisions do not align. Create and assign custom subcases on demand to different teams to tackle issues simultaneously. Track case histories with detailed documentation, offering transparency and accountability. Utilize a comprehensive dashboard for real-time case oversight, periodic status updates, and generate print packet case summaries.
Automated Correspondence and Timely Communication
Generate CMS-compliant letters without manual intervention. Ensure timely communication with members and providers through letters, faxes, emails, or queue calls. Manage written and oral notification timeliness seamlessly, with escalation when needed. Access the content library to store best practice resolutions and guide resolution strategies effectively.
Comprehensive Reporting and Quality Assurance
Generate productivity reports, fetch operational reports, custom business reports, and adhere to compliance requirements. Conduct random sampling for pre-QA and post-QC to assess coordinators’ efficiency and work accuracy in Medicare. Strengthen decision-making with analytics to identify bottlenecks and improve operational outcomes.
Explore Other Solutions for the Payer-Member Journey
Member Portal
Empower members with instant access to information, enhancing convenience and engagement
Enrollment Case Management
Optimize enrollment with an automated, customized system while improving accuracy
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
Find Your Winning Strategy with Newgen
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