Appeals and Grievances for Health Payers

With unpredictable volume, varying service agreement levels and concerns ranging from procedural issues to – quite literally – matters of life and death, managing insurance appeals and grievances (A&G) is a complex, labor-intensive process – especially when managed manually.

By automating much of the A&G process, OnBase expedites case distribution and prioritization while balancing workloads.

Automation for Appeals & Grievances

With automation and case management tools, the OnBase A&G solution streamlines the entire appeals and grievances process to help health payers:

• Process high volumes quickly and more accurately
• Address issues in real-time through greater process visibility
• Improves response time for providers and members

Capture and classify

At the point of capture, OnBase automatically classifies materials against a set of criteria to determine if the appeal is life-threatening, in that it requires medication correction or medical treatment, or if it's monetary, such as an adjustment to deductible, etc., and then routes assignments accordingly.

Workflow expedites reviews and approvals

Using an easy-to-use, easy-to-access interface, providers may submit A&G materials directly to OnBase through a portal, immediately triggering workflow. OnBase automatically routes information for review and approval, and when appropriate, creates the correct correspondence – whether that's an initial acknowledgement letter, a determination letter, or a payment authorization notice.

Provides full audit trail and visibility

By streamlining what was once a high-volume as well as time- and labor-intensive process, OnBase offers payers an efficient way to manage healthcare appeals and grievances. The solution also makes audits more efficient, too, by keeping an audit trail of the entire A&G process with full visibility into what approvals and documents were distributed, complete with date and time stamps.