PCT Grievances and Appeals

PCT Grievances and Appeals.

Process Communication TrackingTM Grievances and Appeals(PCT G&A) gives your organization the ability to process its Grievances and Appeals utilizing a highly configurable state of the art system. PCT-G&A effectuates the creation, tracking and resolution of Grievances and Appeals through Workflows organized as dynamic sets of Action Items centered on a Case. The details of a Grievance or Appeal are entered into a Case; the referencing and scoring of related entities are conducted through the use of Quality of Care and Quality of Service point systems; and the capture of documents and decisions used in arriving at the resolution of the case are saved for future reference. The Outcome of each Action Item sends the Workflow along its configured path (defined by your process) until the Case reaches a resolution. In instances where the Grievance or Appeal must be revisited, support is available for multiple levels of extended or escalated activity including independent external reviews.

A multitude of features are available including:

Configurable for various products (HMO, PPO, POS, ASO) and lines of business (Medicare, Medicaid, Commercial, Health Exchange).

Standard G&A action items include Clinical Case Summary, Case Review, Case Recap, Quality Case Summary, Claim Information and Outcome.

Representation of a workflow as a set of Action Items organized into a Case.

Intake process that accepts initial data either manually entered or retrieved from an external system/application to initiate a case.

Ability to maintain letter templates using MS Word's mail merge feature to insert PCT database fields and the free fields defined for each template.

Configurable role based security that controls the type of access granted to individuals and business units for workflow types, cases and action items.

Automatic and manual assignment of Action Items and Cases to specific organizational units or individuals with load balancing.

Supports progression of a case to the next step via links on the current action item that represent possible outcomes.

Provides for automatic creation of action items based on the status of one or more action items.

User maintainable code tables to support various drop down lists within forms.

Ability to search action items and cases with filters for deadline dates, user and team assignment, workflow type, member/provider name and priority.

Ability to preview letters in PDF format prior to saving them to the PCT database and sending them to configurable network/local printer queues.

Robust and flexible configuration tools that allow for customization of workflows, role based security, assignment of cases and action items, code table maintenance and correspondence template maintenance; all without the need for IT programming or database restructuring
• Integration to legacy systems to retrieve data such as member demographics, member eligibility, provider assignments, providers with their affiliations, claims, UM data, etc. to support case research and resolution.

Supports generation and tracking of letters such as ACK, AOR, RFI, Extension and Resolution using client maintained templates with attachments, retrievable PCT database values and free fields (text, date and time, checkbox) that can be dynamically added to the correspondence action item forms which allow user entered values to be inserted into the letter templates when the letters are requested.

Ability to group letter templates by letter type, line of business, member's state and language to display only the relevant templates in correspondence action item forms.