Digital. Dynamic. Dependable.
Meeting Every External Review Deadline for Denied Claims with CMS-compliant Governance
Process external reviews for denied claims, covering IRO selection, document assembly, and timeline compliance. Ensure CMS-compliant workflows, intelligent case files, and full audit readiness.
“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 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-powered Automation for External Review Cases
Simplify and accelerate external review processing while leveraging intelligent mailroom capability. Identify and classify documents, including IRE and Maximus forms, and then route them automatically to the correct process. Eliminate manual sorting, ensure accurate processing, and enable faster, compliant resolutions.
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-powered Automation for External Review Cases
Simplify and accelerate external review processing while leveraging intelligent mailroom capability. Identify and classify documents, including IRE and Maximus forms, and then route them automatically to the correct process. Eliminate manual sorting, ensure accurate processing, and enable faster, compliant resolutions.
Learn What NewgenONE External Review Solution 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/C2C and similar independent review entities, including pharmacy-related external reviews, 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
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 including medication and formulary information. Integrate external review decisions into AI-assisted processes to enhance Level 1 case outcomes
Explore Other Solutions for the Payer-Member Journey
Member Portal
Empower members with instant access to information, enhancing convenience and engagement
Member Enrollment
A proven one-size-fits-all product enrollment framework, designed to fit the plan’s specific rules.
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
Recommended for You
Find Your Winning Strategy with Newgen
Schedule a Demo to See Newgen’s Payer-Member Solution in Action
Request a DemoGot Questions?
Enter your information, and a Newgen representative will be in touch shortly.
Orchestrate for an Intelligent Enterprise, Now!
Explore all the ways you can tap into orchestration to transform your business for the era of intelligence!
