Transforming appeals and grievances in healthcare

Automate the A&G process for Medicare, Medicaid and commercial payers

To provide members and providers with the service levels they expect, healthcare payers must offer quick, accurate and quality responses while managing high volumes through a time-intensive process.

With the Hyland Appeals and Grievances solution, healthcare payers can improve compliance, increase productivity, improve quality scores and boost member and provider satisfaction. Medicare, Medicaid and commercial insurance can streamline their appeals and grievances lifecycles with automated processing, communication and reporting.

How the Hyland Appeals and Grievances solution works

Hyland A&G solution benefits

Hyland A&G solution key features

Reporting dashboards

Gain actionable business intelligence on focus areas ranging from financial risk to inventory management. Seven standard dashboard reports are included and more can be added for real-time business insights.

  • Ensure case compliance with visual alerts
  • Fully customizable by business users
  • Access cases directly from dashboards
  • Filter and splice data in real time
Gain actionable business intelligence with dashboards.

Automated correspondence

Take the guesswork out of document creation: Automatically generate the right letter at the right time, using the right verbiage to meet quality standards.

Automatically generate the right letter at the right time.

Multiple intake methods

Receive case requests through a variety of channels including: Email, fax, postal mail, phone or online portal. Use intelligent classification to automatically select the case type and ensure that the required information is captured.

  • Gain intelligent, rules-driven case intake
  • Automatically classify case type by LOB
  • Integrate with member service applications such as Salesforce
Intelligent classification automatically selects the case type and ensures that the required information is captured.

Regulatory reporting

Create ODAG universes, CDAG universes and other reports with a single mouse click. Produce custom reports that surface any data created or accessed by the case.

  • ODAG and CDAG universes and timeliness monitoring
  • Quarterly data submission for CMS
  • Wizard-driven customer reporting interface
Create ODAG universes, CDAG universes and other regulatory reports with a single mouse click. 

A&G solution for Medicare

Universes

Save time with pre-built CME universe tables that are automatically populated. Easily search tables and export data to Excel.

Compliance

Meet CMS compliance deadlines and regulatory requirements more easily and intelligently request the proper documentation throughout the process.

Data submission

Create and store quarterly data validation reports for annual submission. Ease the administration of reporting and audit preparation processes.

Universal A&G for Medicaid and commercial payers

Meet regulatory requirements

Configurable reports meet federal and state regulatory requirements. Use multiple independent review organizations and designate the pattern in which appeals get assigned. Modify rules, process guidance, SLAs and reports as needed.

Make changes flexibly

Set individualized rules and activities per plan and/or state. Easily administer and change how cases are managed and processed. Modify rules, process guidance, SLAs and reports as needed.

Customize reports

Customize reports based on plan or state guidelines with specific classification and terminology, and plan and plan-level-specific activities such as verbal acknowledgements, automatic extensions and priority review.