Appeal
An appeal is a request for your health insurance company, the health insurance
payers from the provider, or the patient to review a decision that denied an
authorization. To create an appeal case, in the Patient 360 profile of a specified member, click For more information about appeal case management, see the Pega Care Management
Business Use Case Guide. The following list describes items that are related to the Appeal Microjourney: In App Studio, you can view the data model for Appeal in Case
types. Click the Data model tab on the Appeal
page. To create an appeal case in the Pega Care Management application, fill in the
required details such as contact channel, urgency, requesting provider, member, and denied
authorization list. Use the following rules to configure a different source based on your
organization's requirements. pyContactChannel Urgency D_GetProviderList D_MemberPresentFuturePol D_ListOfDeniedAuthorizations FinalDisposition After the intake is complete, appeals are routed to medical directors for review.
During the review, if the appeal is approved, then the system captures
CertificationIssueDate and
CertificationEffectiveDate as system dates and
CertificationExpirationDate based on the authorization type, for
example inpatient or outpatient. Use this decision tree rule to make updates to the expiration days based on the request
type. Based on the decision outcome, the status of the authorization is set. You can update
the status of the authorization based on the authorization decision and the reject reason
that you configured. For example, you could change Reject to
Denied. Based on the appeal decision outcome, correspondence is sent to the respective
parties. You determine the correspondence template by using a decision table. Use the ResolutionCorr decision table. Data model
Rules for the list of sources in the appeal intake
Key rules for the list of sources
Step in the intake and rule name Rule type Purpose Metadata Property - Field value
Source for the Contact channel drop-down list
(CL:PegaHC-AGWork) Metadata Property - Field value
Source for the Urgency drop-down list
(CL:PegaHC-AG-Work) Select requesting provider
Data page Searches for the requesting or service provider Select
Member Data page Searches for member policies. Member ID is the parameter. Select prior Auth
request Data page Searches for denied authorizations from which you can choose for the
appeal case. Member ID is the parameter. Property - Prompt list Source for the Final disposition drop-down
list. If you choose Uphold, then the
Approved days, Status,
and Reject reason fields are read-only. If
you choose Overturn, you can edit the fields. Updating the number of expiration days based on category code
Rule for expiration days
Rule name Rule type Purpose SetExpirationDays Decision tree Sets the number of expiration days based on the category code Updating the status based on the decision
Rule for updating the resolution status
Rule name Rule type Purpose ResolutionStatus Decision table Evaluates the resolution decision based on the authorization
decision and the reject reason, if applied Determine resolution correspondence template
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