Effectively Handle Complaints to Medicare with AI

Digital. Dynamic. Dependable.

Simplify CTM response workflows with CMS-compliant routing, SLA tracking, and root cause analysis. Ensure orchestrated, timely, and accurate responses that protect Star ratings and demonstrate regulatory diligence.

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“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 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, 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.

AI/ML-backed CTM Handling

Optimize the end-to-end process by automatically capturing, classifying, and routing CTM-related communications. Eliminate manual handling, ensure timely case intake, and improve accuracy. Drive faster, more efficient complaint resolution while adhering to regulatory mandates.

Efficient Case Management

Unified Information Capture and Processing

Automated Communications, Audit Documentation, and Packet Generation

360-degree Case Visibility, Decision Support, and Integration

AI/ML-backed CTM Handling

Learn What NewgenONE Complaints to Medicare (CTM) Solution 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.