The Xerox Workflow Automation Solution for Appeals and Grievances is an enterprise-grade software designed specifically for Healthcare Payers and Insurers to streamline and automate the highly manual and time-consuming process of managing member and provider appeals and grievances.
The solution leverages intelligent workflow automation, capture, and content services to transform paper-driven and portal-based submissions into a fast, digital, and trackable process. By automating key administrative tasks, the software aims to reduce time, labor, and costs associated with manual processing by 30%–50% per appeal.
Key Features and Capabilities
- Intelligent Intake & Classification: Providers and patients submit materials through an easy-to-use interface (handling hard copy, fax, and online portal inputs). The system captures, classifies, and prioritizes information, including determining if the appeal involves a life-threatening situation.
- Automated Routing & Assignment: Assignments are prioritized, evenly distributed among coordinators, and routed to the right parties for review and approval, ensuring tight deadlines are met.
- Detailed Audit Trail & Tracking: The system maintains a detailed, trackable trail of every approval and document, which is critical for compliance and regulatory reporting.
- Real-Time Reporting: Provides real-time reporting and dashboards to address status issues and monitor performance metrics.
- Automated Correspondence: The system can automatically create and send an acknowledgement letter, determination letter, or payment authorization notice.
- Document Management: Capabilities include correspondence generation, high-speed scanning of paper claims, automatic fax distribution, and secure document storage.
Target Users and Benefits
This solution is targeted at claims, compliance, and administrative teams within major healthcare payer organizations. The primary benefits include improving response time for members and providers, maintaining regulatory compliance (e.g., HIPAA), and freeing up staff for higher-value tasks.
