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Grievances & Appeals Module

Member and provider grievance management including intake, investigation, appeal processing, and resolution tracking with regulatory timeline compliance.

4
Pages
4
API Endpoints
3
High-Priority Orgs
5
Requirements

Organization Relevance

MCO: High Health Plan: High TPA: High IPA: Medium ACO: Medium PHO: Medium FQHC: Medium MSO: Low

How It Works

Grievances and appeals enter through intake channels (phone, portal, mail). Each case is categorized, assigned, and tracked against regulatory timelines. Investigation workflows gather evidence and document findings. Appeal processing follows CMS and state-mandated procedures including expedited review options. Resolution tracking ensures closure with appropriate member notification.

Requirements

  • Regulatory timeline tracking (CMS, state-specific)
  • Case management workflow
  • Letter generation (acknowledgment, resolution)
  • Reporting for regulatory submissions
  • Escalation to IRE/external review

Target Audience

Grievance Coordinators, Appeals Analysts, Compliance Officers, Member Services

Pages (4)

PagePurposeKey Features
Grievances Dashboard Overview of grievance and appeal cases with metrics and timelines Case metrics, Timeline compliance, Category distribution, Trend analysis
Grievance Intake New grievance and appeal case creation and categorization Case creation, Category selection, Priority assignment, Initial documentation
Appeals Processing Appeal case management including clinical review and determination Appeal workflow, Clinical review, Determination recording, Letter generation
Resolution Tracking Track grievance and appeal cases to resolution with outcome documentation Resolution workflow, Outcome recording, Member notification, Quality feedback

API Integrations

  • Grievance intake API
  • Case management API
  • Letter generation API
  • Regulatory reporting API

Referenced Resources

  • CMS Grievance and Appeals Requirements (42 CFR 422.564)
  • State grievance regulations
  • NCQA G&A Standards
  • URAC Health Plan Standards

Expected Results

Compliant grievance and appeal processing with regulatory timeline adherence, transparent member communication, and quality improvement insights.