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Appendix A: Implementing the Appeals and Grievances application

Updated on April 23, 2021

The Appeals and Grievances Manager (AGM) application in Pega Foundation for Healthcare leverages the stage-based case management capabilities of Pega Platform to manage the complaints received from members and other interested parties (authorized representatives, providers, and third parties such as independent review entities). It provides the capability to create new cases (work objects) for different types of complaints (appeals, grievances, and organization determination) and processes them through to resolution.

Pega Foundation for Healthcare

The following are the key features of AGM:

  • Stage-based case life cycle using the Pega Platform Case Designer to showcase the Complaint (Appeal or Grievance) process. Each of these are configured as case types and stages are designed to describe each step or process beginning with the creation of the complaint and ending with its resolution. The parent case type is Complaint. Within the parent case type, you can create one or more Appeal and Grievance subcases.
  • Grievance Management Workflows – Start-to-end process for managing member grievances. This process includes the creation of a grievance case, capturing required information, including information about the requestor party and the grievance reason, assigning standard or expedited urgency status, and applying appropriate service levels to ensure timely processing.
  • Appeals Management Workflows – Start-to-end process for managing appeals filed for denial of service or claim payment. Capabilities include the creation of an appeal case, capturing required information, including information about the requestor party, appeal level, appeal category, service and or claim information, assigning an owner and standard or expedited urgency status, and applying appropriate service levels to ensure timely processing.
  • Directed Web Access for External Users – A secure one-time link to the system sent to the provider who is the subject of a grievance, to seek feedback on the issue when the grievance is related to providers or provider office staff (such as, appointments, staff behavior, and prolonged wait times). After the provider submits the required information, the process automatically resumes and is routed to the owner of the case for review.
  • Service Levels, Routing, Prioritization, and Escalation – Tracking of each complaint case with priority assigned based on urgency status, type and level of complaint, and type of denial. Service level rules monitor goal and deadline times based on predefined standard parameters (14 days or 30 days). When the case reaches goal times, additional priority points escalate the case relative to other cases in the queue. Routing capabilities include requesting input from supporting departments such as provider network services or utilization and claims management.
  • Correspondence Generation – Pre-configured letter templates for communicating with the involved parties at various stages of the complaint process. You can quickly and easily customize standard templates for acknowledging a complaint, requesting additional information, and communicating final disposition to meet your specific needs. The letter templates are dynamically compiled and include re-usable correspondence fragment rules for common sections such as headers, footers, style sheets, and logos. You have the flexibility to generate correspondence automatically in the background, or to allow and require editing as well as verification before you finalize it.
  • Quality Improvement Audit – Pre-configured auditing of complaints based on frequency for a specific provider. The process creates a quality review case that is forwarded to the Quality Improvement department for further review.
  • Legacy System Information – Retrieval and display of commonly referenced legacy system information such as member’s eligibility as well as processing feedback comments from all involved parties (member research and provider network departments).
  • Reporting – Pre-configured productivity reporting to track process assignments, activity, quality, and performance. The Reporting Wizard allows managers to build custom reports necessary to manage the complaint resolution processes.
  • Connectors to External Systems – Leverage of the comprehensive integration capabilities of Pega Platform. The complaint management process enables the retrieval and display of pertinent information from the health plan’s existing legacy systems, making it readily available for users during the process of resolving the complaint. The member’s eligibility information and the original authorization or claim information are automatically retrieved and made available as part of the case history. This availability avoids the need to toggle back to legacy systems for lookup and research of the information required to efficiently resolve the complaint.

Appeals and Grievances provide the foundation for health plans to build for change. It comes with a working configuration that you can extend to create your own solution. The remaining part of this chapter provides some suggestions as to where you might extend Appeals and Grievances.

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