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

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Enter your content below. Use the basic wiki template that is provided to organize your content. After making your edits, add a summary comment that briefly describes your work, and then click "SAVE". To edit your content later, select the page from your "Watchlist" summary. If you can not find your article, search the design pattern title.

When your content is ready for publishing, next to the "Request to Publish" field above, type "Yes". A Curator then reviews and publishes the content, which might take up to 48 hours.

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Enter your topic description[edit]

PFHC’s Appeals & Grievances (AGM) 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 SLAs 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 more information on Appeals and Grievances, please click on these links (Add Links here).

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 PFHC’s AGM 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.

Before you begin[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 achieve objective[edit]

In PFHC’s AGM 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 (Add link here).  

  1. Request source: Member
  2. Requested urgency: Standard
  3. 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 (Add link here).

  1. Category: payment/co-payment
  2. Reason: plan responsibility
  3. 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 (Add link here).

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.  PFHC automatically generates communication 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 SLA metrics.  

Tip:  PFHC 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 standards.  For a discussion on this feature, please click on the following link (Add link here).

Tip:  SLA metrics are also dynamically implemented based on the member’s line of business.  For more information on dynamically configured SLAs, please click on the following link (Add link here).

The user navigates through the post-service appeal process with the following steps. For a discussion on each of the steps, please click on the following link (Add link here).

  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, and 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 selecting mail channel during the Resolve step was selected, the user may customize the standard letter to the member.  For a discussion on editing the letter to the member, please click on the following link (Add link here).

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.