Appeals and Grievances

The growing importance of consumer experience in healthcare makes handling appeals and grievances especially critical. The capabilities in Jiva ensure a user-friendly, efficient process that helps safeguard a positive experience for the consumer and a simplified workflow for healthcare reviewers and other users.

Jiva appeals support commercial, Medicaid, and Medicare Advantage lines of business. While typically used for first- and second-level appeals, it can accommodate multiple levels. During the review process, the case or episode can be routed to designated users, including physician reviewers, with supporting clinical documentation attached. Once the investigation and determination are complete, an appeal-decision letter is automatically generated and sent, simplifying the process and expediting the process.

For grievances, Jiva offers intuitive workflow questionnaires designed to arrive at a resolution quickly and efficiently. Trackable complaints or grievances can be assigned automatically to appropriate staff. Once complete, the individual who filed the grievance is notified of the decision. The grievances capability supports multiple complaint types and helps satisfy compliance obligations, with the Medicare Advantage version supporting CMS part C (ODAG) requirements and reports.