Grievances & Appeals

Insurance carriers are under continuous pressure to reduce costs — while simultaneously improving quality, accuracy, consistency and service to members and providers. Insurance carriers strive to keep the percentage of claims that are ultimately grieved or appealed low. While laws and policies may vary as to how the appeal is handled, based on type (e.g. Medicaid, Medicare, SLAs, etc.), most laws and/or policies stipulate that appeals to claims decisions regarding the amount paid or the denial of a claim be acknowledged within three days of receipt.

Within 30 days, the payer often must uphold, amend or reverse the initial decision. Although response time requirements vary among plans, when a member files a grievance against the payer, or one of their providers, it is clearly in the best interest of the plan, the member, and the provider to respond as rapidly and accurately as possible.

The ability to share files for team decision-making is vital to the process. Because of the number of departments that may be involved, being able to control and enforce due dates for actions, as well as secure access to documentation throughout the enterprise, is a must. The ability to report on the grievance or appeal process for auditing purposes is paramount.

The IPD Solution
Although no system can completely eliminate the occurrence of Grievances and Appeals, Ultera provides the carrier's team with the tools necessary to address them with the utmost speed and efficiency, saving the organization money, ensuring compliance via easily tracked audit trails and expedient processes, and promoting customer satisfaction among members and providers.
Ultera quickly moves paper grievances and appeals to digital form and routes them automatically and securely, reducing cycle times dramatically. Automation of processes enables payers to manage the Grievances & Appeals process smoothly, efficiently, and economically, complying with regulations and meeting members’ expectations by:

• Managing work and flagging cases that must be addressed immediately
• Reducing response times and operational costs related to overnight delivery, copy and fax expenses
• Reducing or eliminating risks associated with managing the paper documents
• Maintaining a complete audit trail of all activities for reporting purposes.