Appeals & Grievance

The right letter, text, email, or call — triggered automatically, delivered compliantly.

The Omni-Channel Notification Agent automates the regulated communications that plans must send across Care Management (CM), Utilization Management (UM), Appeals and Grievances (A&G), and Claims.

Automate regulated communications in compliance — mail, SMS, email, and AI voice:

• determination letters
• acknowledgments
• status updates
• resolution notices

Each communication is triggered by a case event, generated from an approved template, delivered in the member’s language, and timestamped for compliance.

Guarantee adverse determinations go out:

1. Within the regulatory window
2. Expedited acknowledgments happen in hours
3. Without hand-generating correspondence by your staff

Plans see roughly 75% time savings on notification workflows. Now you can eliminate the missed letters that plague audits.

From any channel to open case in 2 minutes — classified, verified, and triaged.

Imagine what’s possible in under 2 minutes. The Intake Agent turns a request — fax, letter, phone call, web portal, or email — into a structured, classified UM, A&G, or Claims case. In no time at all, you have a structured, classified UM, A&G, and Claims case.

The Intake Agent automates 95% of your intake process:

• classifies request type
• AOR documentation verified
• expedited requests flagged
• each case routed to the right queue

Clear the intake backlog that’s putting you at risk. Before a case even opens, you’ll catch expedited appeals on arrival — no more days later in a mailroom queue. Circumvent intake staff redeployment by automating upon receipt.

The clock starts at receipt, making automated intake a plan’s single highest-impact step toward timeliness. Trigger an automated workflow from receipt, and the clock stops being the enemy; it becomes the reward.

Full member clinical picture, summarized in seconds.

Find the clinical story with complete, real-time data. The Clinical Summary Agent builds clinical summaries from every available source:

• Claims
• UM history
• care management
• call notes
• medical records

Clinical summaries are tailored to whoever needs them:

• care managers preparing outreach
• medical directors reviewing UM cases
• A&G coordinators assembling appeal files

Summaries are CMS Interoperability compliant and cut preparation time by as much as 80%. Eliminate hours of clinical staff rebuilding member histories from fragmented systems. Now you can give every reviewer a consistent evidence picture, and accelerate any workflow that starts with “What’s the clinical story here?”

Every appeal decided on complete evidence — defensible, documented, done.

The A&G Decision Agent assembles the whole evidence picture:

• clinical summaries
• prior authorization history
• claims
• care management records
• medical records
• drafts an evidence-based decision recommendation

With the A&G Decision Agent, nothing is decided on a partial file. Every recommendation traces to its supporting evidence.

• resolve cases well within 30-day and 72-hour timelines
• reduce IRE-level overturns by getting first-level decisions right
• ensure that when a regulator pulls a file, the evidence trail is complete and organized

Reviewers report roughly 70% time savings.