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Healthcare Appeals and Grievances management

Updated on April 12, 2021
Pega Foundation for Healthcare Product Overview

The Appeals and Grievances application packaged with the Foundation provides end-to-end workflows and capabilities to manage complaints received from members and other interested parties (authorized representatives, providers, and third parties such as independent review entities). The Complaint, Appeal, and Grievance case lifecycles include intake, research, routing options to various support teams like membership, provider, claims, utilization management, clinical and administrative reviews and notifications of receipt and final disposition. The application also includes various SLAs that drive automation and compliance and pre-configured operational and compliance reports. SLAs can also be configured to be automatically driven by line of business associated to the member’s plan. The Foundation also enables the user to automatically generate letter correspondence based on that member's line of business. This can be accomplished by creating and storing letter templates typically used in the Appeals and Grievances process that can easily be customized to meet business needs and ensure regulatory compliance. In addition, the Foundation’s Appeals and Grievances application includes report definitions that support substantial compliance with CMS Part C Organization Determination Appeals and Grievances (ODAG) and Part D Coverage Determination Appeals and Grievances (CDAG) reporting requirements, including the capability to directly upload data in Excel output format.

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