Create a Post-Service Appeal in Pega Foundation for Healthcare’s Appeals and Grievances Manager Layer

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Create a Post-Service Appeal in Pega Foundation for Healthcare’s Appeals and Grievances Manager Layer

Description Learn how to create and handle appeals claims in Pega Foundation for Healthcare’s Appeals and Grievances manager layer.
Version as of 8.1
Application Foundation for Healthcare
Capability/Industry Area Healthcare



Pega Foundation for Healthcare’s Appeals and Grievances layer manages complaints from members, providers, their authorized representatives, and 3rd-party entities such as independent review organizations. The beginning-to-end workflow includes multiple steps in which critical data is collected and automatically routed to individuals tasked with reviewing and rendering decisions on those complaints. The entire process is driven by flexible, user-configured Service Level Agreements to ensure the various steps comply with business and regulatory standards. 

An appeal is a type of complaint where a member or provider seeks to have an adverse decision reversed or mitigated based on a review by healthcare professionals. Appeals can be for adverse decisions made either before (pre-service appeal) or after (post-service appeal) the delivery of a service. This document articulates the approach for creating and resolving a post-service appeal.

For a business overview of Appeals and Grievances, please click on the following link and navigate to the Business Overview chapter in the Appeals and Grievances Business Use Case Guide.

Use case example[edit]

A member appeals a decision by its health plan to deny a claim for physical therapy visits after the services were delivered, because the plan determined those services were not medically necessary according to its published policies. The appeal is managed in Pega Foundation for Healthcare's Appeals and Grievances Manager layer, which collects and distributes required information to medical professionals (i.e., nurse reviewer and physician) for a formal review and disposition. In this scenario, the plan upholds its original decision and denies the member’s appeal. The appeal decision is then communicated to the member.

Demoing the scenario[edit]

A denied claim for physical therapy services associated to the member selected in this appeal is recommended for demoing this scenario.

Process/Steps to create an appeal[edit]

In Pega Foundation for Healthcare's Appeals and Grievances Manager layer, create a new complaint case. Select the parameters below to complete the Complaint overview step. For more information on creating a complaint please click the following link and navigate to Use Case 1: Create Complaint in the Appeals and Grievances Business Use Case Guide.

  • Request source: Member
  • Requested urgency: Standard
  • Service type: Post-service

Complete the Requestor information step.

Configure the Complaint details step using the parameters below to ensure the creation of a post-service appeal. For more information on creating complaint reasons, please click on the following link and navigate to the Add reason step of Use Case 1: Create Complaint in the Appeals and Grievances Business Use Case Guide.

  • Category: payment/co-payment
  • Reason: plan responsibility
  • Claim: Select from the drop-down list the claim referenced in the "Before you begin" section.

Tip:  The combination of complaint category and reason will drive the creation of the correct complaint sub-type, in this case a post-service appeal. For information on complaint types based on selected category and reason combinations please click on the following link and navigate to table at the end of the Add reason step of Use Case 1: Create Complaint in the Appeals and Grievances Business Use Case Guide.

Once the complaint case and appeal sub-case have been created the user may now open the appeal sub case and begin entering the required data. Pega Foundation for Healthcare automatically generates communication to the member acknowledging the creation of the appeal, along with information about the anticipated timing of the appeal’s resolution based on the pre-configured Service Level Agreement parameters.  

Tip:  Pega Foundation for Healthcare will automatically generate emails and/or letters to the parties involved in the appeal at various stages of the process. Letter correspondence is dynamically generated based on the member’s line of business (e.g. government, commercial) to accommodate variations in regulatory and business standards. For a discussion on configuring letter correspondence, please click on the following link and navigate to the Correspondence Templates section within the Delivery stage chapter in the Appeals and Grievances Implementation Guide.

Tip:  Service Level Agreement parameters are also dynamically implemented based on the member’s line of business. For more information on dynamically configured Service Level Agreements, please click on the following link and navigate to the Configuring Service Level Agreements section of the Appeals and Grievances Implementation Guide.

The user navigates through the post-service appeal process using the steps below. For a discussion on each of the steps, please click on the following link and navigate to the Appeal - Use Cases 5 through 7 sections of the Appeals and Grievances Business Use Case Guide.

  1. Research: The gathering of pertinent member information, including justification for the member’s appeal. 
  2. Nurse Review: The review of data and justification for upholding or overturning the original adverse decision, based on plan business and clinical policies. In this step, the reviewer may also adjust the entire claim or certain claim lines.
  3. MD Review: A physician reviews the case, including the nurse reviewer’s findings and decision. The physician reviewer may either uphold the nurse reviewer’s decision, or override some or all of that decision.
  4. Resolve: In this step the plan communicates the appeal decision and justification to the member. Both verbal and written communication are provided.

Tip:  If the mail channel was selected during the Resolve step, the user may customize the letter being sent to the member. For a discussion on editing the letter to the member, please click on the following link and navigate to Use Case 8 - Communicate

appeals resolution in the Appeals and Grievances Business Use Case Guide.

Results[edit]

Upon completion of each of the steps in the post-service appeal workflow, both the appeal sub-case and complaint case are automatically resolved-completed.