Dynamically Driving Appeals, Grievances, & Organization Determination Sub-Cases from a Complaint Case

Dynamically Driving Appeals, Grievances, & Organization Determination Sub-Cases from a Complaint Case

Description	How to create complaint category and reason combinations to drive appeals, grievances, and OD sub-cases.
Version as of	8.7
Application	Pega Foundation for Healthcare
Capability/Industry Area	Healthcare and Life Sciences

Overview

Pega Foundation for Healthcare’s Appeals & Grievances Management (AGM) application enables the user to create and resolve complaints from healthcare consumers and/or their authorized representatives, healthcare providers and 3^rd party entities such as Independent Review Organizations.  Each complaint or “Parent” case begins with an intake step in which the user gathers basic data, and then leverages an automated intelligent workflow to dynamically drive the creation and resolution of 3 discrete “child” or sub-case types.

•  Appeal, where a member or provider seeks to have an adverse decision, such as a claim or authorization denial reversed or mitigated based on a review by healthcare professionals.

• Grievance, where a member or provider seeks resolution for an unexpected or unacceptable event, such as restricted access to service, poor quality of care, or poor treatment (For example, rudeness/disrespect).

• Organization determination (OD), where a member or provider requests an exception to a routine process, service or payment limitation based on extenuating circumstances.

Dynamically driven complaint sub-cases

During the execution of the create complaint workflow, the user enters the initial complaint case information (step 1), then provides the requestor data (step 2) as indicated below.

In the 3^rd step of the workflow, the user specifies the complaint details by selecting a combination of complaint category and complaint reason from the 2 displayed fields.

Each complaint category dynamically drives the available complaint reason options, and each combination of category and reason drives the creation of a discrete sub-case type, either an appeal, grievance, or OD.

Out-of-the-box category and reason combinations, and their associated sub-case types are shown below.

Complaint Category	Complaint Reason	Sub-Case Type
Payment/Copayment	General dissatisfaction	Grievance
	Amount different from last year	Grievance
	Change in premium	Grievance
	Plan responsibility	Appeal
	Type of service not correct/ or right level	Appeal
	Discontinued service	Appeal
	Timing of plan payment	Appeal
	Should be a covered service /plan responsibility	Appeal
Treatment/Procedure	Notification of termination of service	Appeal
	Notification of denial of service	Appeal
	Reduction of previously approved service	Appeal
	Refusal to authorize service	Appeal
	Request for payment	OD
	Request for service	OD
Provider	Current provider no longer contracted	Appeal
	Timeliness of service	Grievance
	Quality of service	Grievance
	Rudeness/disrespect by staff	Grievance
Health Plan	Enrollment/disenrollment issue	Grievance
	Plan benefit issue	Grievance
	Pharmacy access issue	Grievance
	Customer service issue	Grievance
	CMS issue	Grievance
	Other issues	Grievance
	Process issues	Grievance
	Marketing issues	Grievance
Prescription Drug	Request non-formulary exception – drug not on plan	OD
	Request non-formulary exception – drug no longer offered on plan	OD
	Request formulary exception – Step therapy exception	OD
	Request formulary exception – Request higher dosage or quantity than limit	OD
	Request tiering exception – drug in higher cost share tier	OD
	Request tiering exception – drug moved to higher cost share tier	OD
	Request prior authorization for prescribed drug	OD
	Request out-of-pocket expense reimbursement for covered drug	OD
	Charged copay higher than plan limit for a drug	OD

Before you begin

Log into the Pega Foundation for Healthcare environment as Administrator.  From Dev Studio, click on the Application tab at the top of the landing page and select Healthcare Appeals and Grievances application..

Process/Steps to achieve objective

1. Click on the Data types icon from the left-hand navigation panel.
2. Select Reason for complaint from the Data types list (PegaHC-AG-Data-ComplaintReason).
   
   
3. Click on the Records tab at the top of the page to expose the complaint categories and reasons and then click on the Add record label located in the bottom left-hand corner of the page.
   
   
4. This will expose a row of editable fields. Complete the following fields (see below).
   • Category – Enter an existing category (Health plan, Provider, etc.).
   • Reason – Enter new complaint reason title.
   • ID – Enter the next id number in the sequence of existing reasons.
   • Is Appeal or Grievance – Enter either A for appeal, G for grievance, or OD for Organization determination.
   • Reason type – Enter either Pre service, Post service, or All.
   • Case type – Enter either Grievance, Appeal – claim, Appeal – Auth, or OD.
   • Medicare plan type - Enter either Medicare Part C, Medicare Part D, or All.
     
     
5. When completed, click on the Refresh button in the top right-hand corner of the Complaint reason page.
   
   
   
   

Result

Confirm the inclusion of the new reason and category combination from the 3^rd step of the create complaint workflow. When the user selects the newly configured complaint category and reason combination, the correct sub-case type will be driven off the parent complaint case.

Actual work that is performed by application users and automations that consists of a sequence of tasks and leads to an intended business goal. An example of a case is a process of hiring a particular job candidate, where an HR worker collects necessary documents, a hiring manager conducts a job interview, and an application sends an automated email with onboarding information after the candidate is approved. To create a case, you first build a template of your business process that is a case type, and then apply the template in multiple cases, for example, to review applications from many candidates.

A business solution that automates workflows in your organization. Multiple, unrelated applications can be hosted in the same system. You create an application by running the New Application wizard.

The act of closing a case by recording in the properties that work is complete.

As a case advances through a flow, information stored in its properties becomes more complete through user input and automatic processing. When the work for a case is complete, the case is marked as "resolved", or "closed".

A program component that defines and implements an interface between an external application acting as a client, and a Pega Platform system acting as a server. An external system can send a request to a Pega Platform application and receive a response.

For example, the Pega Cloud Services SFTP service provides Pega Cloud clients with simple, secure file transfers to and from their Pega Cloud applications.

A template for a case in an application.

A single source of information that presents categorized content, such as tabs or tools. You can access information on a landing page with focus on a single category that you want to select. A number of landing pages can be accessed right at the launch of your application. For example, on the Application Quality landing page, you can view the health of your current application and identify improvements to make before you deploy an application.

A business solution that automates workflows in your organization. Multiple, unrelated applications can be hosted in the same system. You create an application by running the New Application wizard.

The left panel of a portal that provides access to data and tools that are relevant to your role.

A collective term that describes a rule instance or a data instance. For example, a customer record would include data specific to a given customer, such as name, telephone number, and customer account number.

A data structure that holds name-value pairs. Pages are stored in the system memory or in the database. Various types of pages are defined in the system, such as data pages that are created when the data is referenced, named and unnamed pages, parameter pages, clipboard pages, and so on. Every unit of information in an application is a pairing of a name and a value, known as a data element. For example, a data element that stores the email address of a customer has the name "email," and the value "john.smith@company.com." Pages store data elements so that the application can use it to process the case.

Actual work that is performed by application users and automations that consists of a sequence of tasks and leads to an intended business goal. An example of a case is a process of hiring a particular job candidate, where an HR worker collects necessary documents, a hiring manager conducts a job interview, and an application sends an automated email with onboarding information after the candidate is approved. To create a case, you first build a template of your business process that is a case type, and then apply the template in multiple cases, for example, to review applications from many candidates.