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.