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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     |    

“Using Newgen’s External Review Solution has made a big-time difference for us. The integrated AI capabilities help us stay compliant and smoothly handle all levels of external appeals and grievances.  It has made a complex process much easier to manage, and we’re delivering better outcomes for our members.”

– Vice President, External Affairs, 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 External Review Solution, from Complaints, Appeals & Grievances Suite, Can Do for You

Comprehensive Support for All Levels of Appeals, Grievances, Complaints, and Disputes

Provide comprehensive support for managing all levels of appeals, grievances, complaints, and disputes. Ensure end-to-end processing, regulatory compliance, and efficiency. Support Level 2 medical appeals, and redeterminations for prescription drugs, reviewed by Independent Review Entities (IRE), Level 3 adjudications by the Office of Medicare Hearings and Appeals (OMHA ALJ), Level 4 reviews by the Medicare Appeals Council (MAC), and Level 5 Federal Court Judicial Reviews. Streamline workflows and ensure compliance at each stage

Intelligent Mailroom, Case Assignment, and Enrichment

Manage external review processes with intelligent mailroom capabilities, automated case enrichment, and smart case assignment. Integrate with electronic communication management for advanced processing of documents. Leverage AI to identify and triage external review case file requests, RFIs, and notices of non-compliance. Alert case owners in real time for immediate action

Agency Case Processing and Packet Generation

Streamline agency case processing by automating case file creation upon receipt. Ensure case files follow their completion cycle. Maintain compliance by auto-updating IRE decisions and promptly sending additional information for RFIs. Generate agency packets automatically for Maximus and similar independent review entities, enhancing efficiency and regulatory adherence

Duplicate Check, Case Collaborations, and Redirects

Enhance efficiency and accuracy with advanced duplicate checks, seamless case collaborations, and intelligent redirects. Automatically detect and flag duplicate entries to prevent fraudulent activities. Identify closed cases with similarities to active ones, offering actionable insights for quick resolution

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Detailed Reporting, Visibility, and Analytics

Generate productivity and compliance reports to identify bottlenecks and streamline workflows. Tailor business insights to meet regulatory and operational needs. Gain complete oversight with a comprehensive dashboard, offering periodic updates and AI-driven insights from past decisions for consistent outcomes

Generative AI for Real-time Insights

Leverage NewgenONE Marvin—GenAI layer—to quickly scan documents and get real-time summaries. Request data from Marvin to receive instant results at your fingertips. Identify and link existing appeals and documentation for any external review. Integrate external review decisions into AI-assisted processes to enhance Level 1 case 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

Medicare CTMs

Fast-track the resolution of Medicare complaints, delivering better outcomes and maintaining strict regulatory adherence

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

Request a Demo

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