The OnBase Appeals & Grievances (A&G) solution to the medical compliance challenge

Drive member and provider satisfaction while enforcing compliance with OnBase

The Centers for Medicare & Medicaid Services (CMS) requires that every appeal and grievance is completely tracked, managed and documented to certain specifications. Getting it wrong can mean lengthy audits, corrective actions and even stiff fines. Most health plans rely on complex manual processes to manage deadlines, expedite urgent appeals, document the appeal process and report internally and outside the organization.

The OnBase Appeals & Grievances (A&G) solution provides a complete approach to this compliance challenge. The solution leverages OnBase’s native case management capabilities, system connectors, letter generation and real-time dashboards to create a self-policing, CMS-compliant A&G process.

  • Systematically enforces CMS compliance

    With appeals coming in from a variety of sources – via paper, fax, email, portals and the phone – it’s difficult to build compliance into processes. With OnBase A&G, every appeal is systematically tracked from receipt through determination, regardless of the source. The A&G solution also creates a complete audit trail that tracks every action with a date and time stamp, including who viewed, edited, printed and routed the appeal.

    To meet CMS’s evolving mandates, OnBase identifies appeals that must be expedited and routes them for immediate action, enforcing deadlines via notifications and escalations. Priorities are easily managed and can be changed throughout the process.

    In addition, a key element for compliance is documenting the review process and notifying stakeholders at the right times. Users are assured that any communication with stakeholders is streamlined, as automated notification letters with pre-approved language take the guesswork out of document composition. Independent reviews are tracked and managed within the centralized A&G solution. And all documents and notes associated with appeals are stored in a secure repository for easy retrieval.

  • Provides real-time process insight

    Knowing appeal status at every step in the process is critical. The OnBase Appeals & Grievances solution provides dashboards that show real-time process details for inventory, productivity, work in process and more. Interactive reporting allows business users to quickly and simply report on everything that happens in the system, without having to make a call to the IT department.

    A deep audit trail offers transparency into all appeals and grievances, tracking every interaction in an accessible database and supporting each determination in an audit. Audits become much less burdensome for health plans as appeals are easy to find and completely documented.

    OnBase connects with thousands of applications, enhancing the value of existing IT investments and assuring users that they have access to the most updated information for every appeal. OnBase A&G gives health plans a 360-degree view of processes and content existing in all their key systems.

  • Improves the A&G experience for all stakeholders

A goal of every health plan is a simple, clear and thorough process for internal and external stakeholders. Doctors, hospitals and members, as well as the employees who are responsible for the appeals process, need to be positively engaged.

With OnBase A&G, appeals personnel are presented with a complete view of each appeal, including all the information they need to complete their role in the process. The customer service department has up-to-date information on the status of the appeals process for each inquiry. Internal auditors have everything they need for well-documented and thorough audits. Plan managers and executives benefit by effectively managing resources while mitigating risk.

Externally, providers receive up-to-date information on appeals. Members can be assured that expedited appeals for services or medications are handled promptly. And State Departments of Insurance and CMS can easily verify that all appeals are managed to the letter of all regulations.


Download the complete Appeals & Grievances
OnBase Solution Summary PDF