Complaints, Appeals and Grievances (CAG)

Ensure timely and effective resolution of appeals and grievances received in any form

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  • Expedite Grievance
    Resolution

    Workflow and auto-prioritization of cases enables better routing with provisions to mange escalations and case exceptions.

  • Ensure Better
    Compliance

    Leverage real-time process reports and extensive audit features to continually monitor milestones and resolution timelines.

  • Multi-Channel Content
    Management

    Capture and collaborate information from multiple sources and unified interface with internal and external systems.

Brochure: Creating an Efficient Complaints, Appeals & Grievances Platform for Healthcare Payers

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Recent regulatory reforms have led to increased enrollment for Medicare coverage and enhanced member rights, causing a steep rise in Complaints, Appeals & Grievances. Customized provider contracts that govern case specific SLAs require close scrutiny for accurate resolutions, making the process extremely cumbersome and time- consuming. Healthcare payers have realized the importance of creating faster and more efficient Complaints, Appeals and Grievances management processes for improving customer satisfaction. Technology can act as an enabler by creating process flows that drive customer satisfaction, while improving productivity and reducing the overall cost of their services.

Newgen’s Complaints, Appeals, and Grievances (CAG) Management solution

Newgen Complaints, Appeals, and Grievances (CAG) management solution delivers robust functionality across the length and breadth of the solution. It provides a business configurable process automation and improvement framework that allows timely resolution of Appeals & Grievances received in any form – email, paper, mail, customer service, web portal, walk-ins, fax, electronic documents etc. The smart rules driven engine prioritizes all transactions for automated routing, ensuring resource optimization, and reduced TATs. It guarantees enhanced customer satisfaction through a robust correspondence management system that initiates appropriate communications at various stages of the process.

Key Features of Newgen’s Complaints, Appeals & Grievances Management Solution

Newgen’s solution suite is a comprehensive and unified Complaints, Appeals and Grievances platform that helps you engender collaborative synergies between providers and members by bringing together the power of 4 Cs –

  • Content Management

    • Automated capture of critical documents such as signature forms, physician reports, etc
    • Storage of attachments, member, provider, claims, and authorization data within the case
    • Secure vault of case documents with access and audit driven rights
    • Rules based routing and redirection of files
    • Version controlled repository of member documents
  • Case Management

    • Seamless intake of data across multiple channels
    • Automated due date calculations, decisions, validations and case prioritization
    • Skill based, role based and case based routing of cases
    • Manage escalations with real time alerts and reporting dashboards
    • Removes process bottlenecks and creates a process improvement culture
  • Compliance Management

    • HIPAA Compliance is met as all access to PHI is secured
    • Role-based, secure access to systems, information, and documents
    • Real time reports on document changes along with timestamps
    • Extensive audit trail with detailed, long-term record for every case
  • Communication Management

    • Automated selection of letter templates with pre-populated information
    • Guided procedures with best-practice-based templates
    • End-to-end process visibility with real time analytics
    • Real-time acknowledgment, notifications & status updates to appellants

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5 reasons why Healthcare Payers must go for an advanced Complaints, Appeals & Grievances Solution

  • Highly regulated, scrutinized and monitored process with significant fines and penalties for noncompliance
  • Communication challenges in providing real-time status updates and time dependant notifications to appellants on their appeals/grievances
  • Need for secure audit trails with issue tracking to assist in future compliance hearings, centralized proof of compliance during CMS, state and service level audits
  • Unique mandated Service Level Agreements (SLAs) and corresponding time tracking in meeting regulatory, operational and service level compliance standards
  • Difficult and time consuming process of retrieving case information from disparate sources