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

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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[edit]

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 3rd 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[edit]

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 3rd 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[edit]

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[edit]

  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[edit]

Confirm the inclusion of the new reason and category combination from the 3rd 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.

Step5 final.jpg