Appeals & Grievances (A\&G)
Appeals & Grievances (A\&G) provides comprehensive workflows to support intake, tracking, resolution, and compliance for member and provider-submitted appeals and grievances. It ensures adherence to regulatory timelines, audit readiness, and operational transparency across all LOBs.
Workflow Architecture
A\&G workflows follow a case-based model with integrated task orchestration. Each case progresses through multiple steps based on appeal/grievance type, source, urgency, and complexity.
Core Workflow Phases:
Case Intake & Classification
Acknowledgment & Initial Routing
Clinical/Non-Clinical Review
Resolution & Notification
Audit & Closure
Each workflow is configurable based on line of business (Medicare, Medicaid, Commercial) and case type.
Case Intake & Classification
Intake Channels:
Member or provider portal
Phone or call center documentation
Mail or fax with manual entry
Delegated entity systems (API or batch)
Classification Rules:
Standard vs. expedited
Appeal vs. grievance vs. complaint
Clinical vs. administrative
Auto-detection of duplicate or related cases
Routing & Processing
Configurable Queues:
Sorted by TAT, LOB, or specialty
Assigned by role (e.g., analyst, clinical reviewer, supervisor)
Reassignment Logic:
Auto-escalation based on case status or time remaining
Manual re-routing with audit trail
Sub-Tasks:
Document requests
Outreach tasks
Review comments
Timeliness and SLA Management
SLA timers and due dates set based on:
CMS, NCQA, and state guidelines
Type of case and urgency
System alerts:
Pending expiration
Required actions
Escalations
Status logs track all compliance milestones
Correspondence & Notifications
Auto-generated Letters:
Acknowledgment, resolution, extension, and closure
Templates:
Configurable by LOB, case type, and channel
Multilingual support
Delivery Options:
Mail, portal message, secure email or fax
Version Control:
Letter history tracked per case with timestamps
Documentation & Attachments
Upload and tag supporting documentation
Link documents to specific tasks or decisions
Integrated with Document Management System (DMS)
External case ID mapping for delegated entities
Audit & Compliance
Full case audit log:
User actions
Task outcomes
Communication records
Preconfigured audit export templates
Role-specific audit views and compliance dashboards
Built-in tracking of overturned decisions and trends
Roles & Access
Intake Analysts
Reviewers (clinical and administrative)
Medical Directors
Supervisors and QA auditors
Delegated partner access (read-only or task-assigned)
Role-based access controls are strictly enforced across case data, documentation, and actions.
Reporting & Oversight
TAT compliance by case type and LOB
Overturn rates and decision timelines
Volume trends and case categories
Root cause and issue types
Delegated vs. in-house case split
Configuration & Extensibility
Workflow templates per case type and LOB
Configurable rules for routing, escalation, and alerts
APIs for external system intake and status update
Custom form builders for intake and resolution summaries