Health Insurance Appeals and Grievances (A&G) is a complex area to manage. Volumes are unpredictable and types of A&G can vary in severity from procedural issues that need timely responses to those that require immediate action, like matters of life and death. Varying service level agreement requirements make this process labor intensive.
By automating much of the manual processes, the OnBase solution expedites the distribution of A&G, balancing workloads. OnBase automatically classifies materials at point of capture, uses a set of criteria to determine if the appeal is life threatening (requiring medication correction or medical treatment) or monetary (an adjustment to deductible, etc.) and prioritizes assignments for A&G coordinators.
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, initiates the type of correspondence to be created (an initial acknowledgement letter, a determination letter, or a payment authorization notice.)
The OnBase Appeals & Grievances solution not only provides an easy way to manage this high-volume, time- and labor-intensive process, it also keeps an audit trail of the entire process, providing visibility into the process, including approvals and documents distributed, complete with date and time stamps.