Appeal & Grievance Intake and Classification

What You Do Today

Something arrives and you have to say what it is before anything else can happen. A member calls because a service was denied. A member calls because she was on hold, then transferred, and no one ever called her back, which is a different thing entirely. A letter comes from a son about his father's care, and whether he is permitted to file at all depends on whether a valid appointment of representative is on file. A physician's office calls on a member's behalf about a service not yet delivered, which is a request for a determination rather than a challenge to one already made. A complaint the member filed through Medicare's own helpline reaches you from a federal system with a clock already running. The line that matters is whether the contact contests a coverage or payment decision the plan made, which makes it an appeal and carries a deadline, a required written decision and a further level of review the member is entitled to, or whether it is a complaint about anything else, access, service, staff conduct, timeliness, quality of care, which is a grievance with its own process and its own clock. Get it wrong in one direction and you have quietly removed a right the member had. Get it wrong in the other and you have built a formal case file around a bad phone call. Then you decide standard or expedited, because a member whose health could be seriously jeopardized by waiting is entitled to the faster track, and a treating physician saying so is enough to put them on it. And one contact is often two cases: the denial is an appeal, the way the denial was explained is a grievance, and both have to be opened.

AI Technologies

How It Works

Classification reads what actually arrived, the call transcript, the letter, the portal form, the record forwarded by a regulator, and proposes what it is: an appeal of a determination already made, a request for a determination not yet made, a grievance, or more than one of those inside the same contact. Speech recognition turns the call into text while the member is still describing the problem, so the classification runs on what the member said rather than on the summary a representative typed afterward. Clock calculation ties case type, line of business and the date the contact was received to the deadline that governs it, including the shorter one that applies once a case is expedited, and tracks the intermediate steps a case has to clear rather than only its final due date. Linking looks for the other records that belong with this one: the determination being contested, an earlier grievance from the same member on the same subject, the duplicate that arrived by a second channel, the representative form filed against a different case months ago.