Manage appeals and grievances
How manage appeals and grievances are reshaped as AGI capability advances.
Business-as-Code
Read as an executable program — the work decomposed into Code, Generative, Agentic, and Human.
Manage appeals and grievances sits inside a larger value-flow — 1 parent structure it composes into. The hierarchy is grounding, not the story: it tells you which aggregate exposure Manage appeals and grievances inherits.
Where Manage appeals and grievances sits
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How the work flows
Trigger: A member, provider, or authorized representative submits a formal appeal against a coverage decision or a grievance regarding service quality.
- Receive and log the appeal or grievance submission
- Triage and categorize the request based on urgency and type
- Gather relevant medical records, policy documents, and prior claim data
- Conduct a clinical or administrative review by appropriate personnel
- Render a final determination to uphold or overturn the original decision
- Generate and send formal notification of the resolution to the stakeholder
- Execute necessary follow-up actions such as reprocessing claims
Outcome: A final determination is reached, the stakeholder is formally notified, and any required adjustments to claims or authorizations are executed.