The examples shown here represent some of the key features of PFHC sample applications.

Example 1: Complaint

• Provides end-to-end workflow processes to capture and manage member complaints.
• The complaint case can contain one or more sub-cases of type appeal and/or grievance.
• Key stages include Intake, Research, Acknowledge, & Resolve.
• The workflow processes include service level (SLA) management, routing, prioritization, and escalation processes. SLAs may be dynamically driven by the member’s Line of Business.
• The workflows have pre-configured and automated correspondence generation for acknowledging the receipt of a complaint, requesting additional supporting information, as well as communicating final disposition of the complaint (approvals or denial letters). Both email and letter correspondence are available.
• Letter templates may be configured and stored by line of business. PFHC includes 2 out-of-the box categories: GVT (for Medicare, Medicaid, and Federal Program LOBs) and Commercial (all other LOBs).

Example 2: Codes

• It provides end-to-end workflow processes to create, search, view, and maintain industry standard code sets and custom code groups in the Foundation.
• The workflow processes include management of code set files as well as the ability to create and maintain custom code groupings.
• The workflows include approval processes by managers.