Appeals and Grievances Software and Solutions For Healthcare

Appeals and Grievances Process Automation Software

Resolve members’ appeals and grievances while complying with regulatory guidelines and adhering to state-level and CMS (Center for Medicare and Medicaid Services) guidelines. Optimize resources and reduce turnaround times by leveraging our rule-driven engine to prioritize and route all service requests. Capture all decisions, notes, and exceptions within the system for future reference and audits. Automate your service requests processes to future-proof your organization, stay on top of regulations, and guarantee member satisfaction.

Duplicate and Previous Case Management

Automatic duplicate checker to flag duplicate entries and avoid fraud
Previous case detection to identify previously closed cases with similarities to active cases and to offer insights to caseworkers for quick case resolution

Intelligent Case Routing and Assignment

Parallel processing to assign tasks to multiple stakeholders during the investigation work step
Intelligent routing with provisions to manage escalations and case exceptions
Auto-prioritization of standard and expedited cases

Automatic Document Generation

Automated generation of correspondences, including acknowledgement and resolution letters, and adherence to regulatory compliances
Automatic preparation of summary documents, including case artefacts and information

360-degree Case Visibility

Comprehensive dashboard to conveniently manage cases
Periodic status reports and member case updates to business managers

Audit Documentation and Packet Generation

Downloadable case packets, containing case information, for internal and external audit use
Data packages for historical and archived cases for CMS auditing

Unified System for Information Capture