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98% Improvement in CMS Compliance     |     90% Reduction in Error Rate     |     50% Increase in Report Delivery Levels    |    50% Enhancement in Adherence to Due Dates     |     | 60% Improvement in External Agency Collaboration     |     75% Rise in Data Validation     |     98% Improvement in CMS Compliance     |     90% Reduction in Error Rate     |     50% Increase in Report Delivery Levels    |    50% Enhancement in Adherence to Due Dates     |     | 60% Improvement in External Agency Collaboration     |     75% Rise in Data Validation     |     98% Improvement in CMS Compliance     |     90% Reduction in Error Rate     |     50% Increase in Report Delivery Levels    |    50% Enhancement in Adherence to Due Dates     |     | 60% Improvement in External Agency Collaboration     |     75% Rise in Data Validation     |     98% Improvement in CMS Compliance     |     90% Reduction in Error Rate     |     50% Increase in Report Delivery Levels    |    50% Enhancement in Adherence to Due Dates     |     | 60% Improvement in External Agency Collaboration     |     75% Rise in Data Validation     |     98% Improvement in CMS Compliance     |     90% Reduction in Error Rate     |     50% Increase in Report Delivery Levels    |    50% Enhancement in Adherence to Due Dates     |     | 60% Improvement in External Agency Collaboration     |     75% Rise in Data Validation     |     98% Improvement in CMS Compliance     |     90% Reduction in Error Rate     |     50% Increase in Report Delivery Levels    |    50% Enhancement in Adherence to Due Dates     |     | 60% Improvement in External Agency Collaboration     |     75% Rise in Data Validation     |    

“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.

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 & Provider Appeals

Simplify the entire process with AI-driven compliance, efficiency, and better stakeholder outcomes

Grievances and Complaints

Manage complaints and grievances that comply with federal regulations and accreditation standards

External Reviews

Optimize external reviews while ensuring transparency and maximizing operational excellence throughout the process

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

Schedule a Demo to See Newgen’s Payer-Member Solution in Action

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