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Grievance - UC 11: Request feedback from external users

Updated on January 31, 2022

AGM system has a prototype of how to request feedback from external users. System sends a secure one-time link in an email to the provider for complaints related to provider. Email shares complaint details and seeks providers feedback on the issue. Email also has a web link. Provider can access that web page and enter provider feedback. This feedback is made available during grievance case resolution.

Pega Foundation for Healthcare
  1. Click +New on dashboard and click New Complaint to create a new complaint.
  2. Select Request Source as Member from the following options:
    • Authorized Representative
    • Member
    • Other Entity
    • Provider
  3. Select appropriate Contact Channel from the following options:
    • Broker
    • Compliance Line
    • CTM
    • DOI
    • Email
    • Fax
    • Mail
    • Phone
    • Web Self-Service
  4. Enter or Select date for Received Date.
  5. Select Urgency and Service Type.
  6. Click Continue at the bottom right of screen.

  7. Enter or Select Member ID and Plan ID to enter member and plan information. System allows user to search by Member Id number, first name or last name. System only allows selecting one member record.
  8. Select one of the members from search results.

    The system displays the following member details:

    • Member Name
    • Date of Birth
    • SSN
    • Email
  9. Select one Plan from the search results.
    • Plan ID
    • Plan Name
    • Plan Type
    • Contract ID
    • Line of Business
  10. Verify Member and plan details and then click Continue.
  11. Click Add reason to add category of complaint and the reason for complaint.

    The system displays the following four categories and associated reasons:

    • Health Plan
    • Payment/Copayment
    • Provider
    • Treatment Procedure
    • Prescription Drug
  12. Select Complaint category as Provider and select one of the below associated reason.

    If the complaint category is Provider, the system gives provision to capture Contact Name, Contact Phone and Incident Date.

  13. Enter comments in Complaint justification to give more details about complaint.
  14. Click Submit.
  15. If required, click Add Reason to add more than one complaint. Repeat steps 12 and 13.
  16. Click Finish at the right bottom of Complaint screen.

    System generates an external feedback case for following combinations of Complaint Category and Complaint reason as per table below:

    Complaintcategory Complaintreason Appeal orgrievance
    ProviderTimeliness of serviceGrievance
    Quality of ServiceGrievance
    Rudeness / disrespect by staffGrievance
  17. Enter the forwarding comment that needs to be sent to provider during research stage of grievance case cycle.

  18. If an email address is configured for Provider, an email is sent to that address.

  19. Provider shares his/her input and clicks submit. Comments are added to the case.

  20. The case is ready for review with both the forwarded comment and provider feedback.

  21. Case decision is taken based on the provider feedback or routed as appropriate.

  22. Grievance is acknowledged and resolved.

  • Previous topic Grievance - UC 10: Review and resolve grievance
  • Next topic Determination - UC 12: Review and research determination case

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