Appeals and grievances management that rebuilds every appeal as a cited story, decided inside its clock
Every appeal decided on time, with the full file read and what is new marked.
See one case, screen by screen ↓Software a health plan uses to take each appeal or grievance from the request in, through review, to a decision and letter inside its regulatory clock, with every step recorded. Appeals & Grievances Management adds agents that sort each letter, rebuild the original file as a cited timeline, mark what is new and re-test the denial against the right policy version.
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When a member or provider appeals a denial, the appeals nurse has to pull the original claim or prior-auth request, the denial notice, the first reviewer's notes, the new records and the medical policy into one case — from four systems — and get it to a physician reviewer inside a regulatory clock: 72 hours, 7, 30 or 60 days. The reviewer then reads the PDFs in whatever order they arrived. A missed reconsideration deadline goes to the independent review entity as adverse.
Most appealed denials do not hold: in 2024, 80.7% of appealed Medicare Advantage prior-auth denials were overturned, fully or partly, so the plan pays for the same review twice while the member waits. Some causes are not clinical at all. Medical policies change every year, and a claim reviewed months after the service — non-contract providers have 12 months to bill — gets tested against the version in force on the review date. HHS-OIG names systems “not programmed or updated correctly” among the causes of wrong denials. And one appeal letter can carry a grievance with its own 30-day clock, easy to miss.
Estimated split of elapsed working days for one payment reconsideration, by hand and with the solution — most of the hand-built time is waiting on records from other systems.
Seven agents rebuild each appeal as a cited story and re-test the denial against the policy in force on the date of service; a physician reviewer signs.
Gloria Trevino, 69, appeals a denied L4–L5 lumbar fusion at Larkmoor Health Plan. Here is her payment reconsideration, screen by screen, in the working solution.
Renee opens the queue: 347 open appeals, 65 open grievances, 9 expedited on 72 or 24 hours, and 23 denials that used the wrong policy version. Gloria's case, A-26-04417, sits at day 14 of 60, 94% likely overturned, flagged wrong version and grievance.
Gloria's mailed letter came with Dr. Mehra's letter of medical necessity, a waiver of liability and a copy of her therapy discharge summary. The intake sorter read it as a payment reconsideration on a 60-day clock, due Fri 27 Nov — and found a complaint about phone calls inside it, which became its own grievance, G-26-01182, on a 30-day clock. In the case file, the passages it used are highlighted.
“I called three times in August and each time I was told it was "in review".”
No stack of PDFs. Across the top, the case in time: the two versions of medical policy MP-212 as bands, with the therapy, the surgery on 16 Dec 2025, the claim on 22 Jul, the denial on 20 Aug and the appeal on 28 Sep pinned on them. Below, five chapters — what was asked for, what was decided and why, what Gloria now says, what is new, what the evidence shows — each with its source page in the margin.
“The denial tested a December 2025 surgery with the 2026 version.”
The denial cited criterion 2 of MP-212 version 2026.1: 12 weeks of supervised therapy. That version took effect on 1 January 2026 — sixteen days after the surgery. Flip the criteria grid from “As applied · v2026.1” to “In force on 16 Dec 2025 · v2025.2” and the answer changes: at least 6 weeks of conservative care, and Gloria had 9 weeks, 17 visits. Four of four criteria met.
Review tool log: “rule=REVIEW_DATE → v2026.1” — the version was picked by review date, not date of service.
Two documents are new: Gloria's letter and Dr. Mehra's, which reports new numbness in her left foot in late November. The therapy discharge summary is marked “Already in the file” — the same 9 weeks the plan had on 11 August, page 31. The draft decision below: overturn in full, pay $31,284.17 to Brightwater Spine & Joint by Fri 27 Nov 2026.
“Nothing new is needed to decide: the records the plan already had meet the policy that was in force.”
Policy versions shows why. MP-212 v2026.1 raised conservative care from 6 to 12 weeks of supervised therapy and added a BMI limit below 40. It was approved on 14 Oct 2025 and published on 1 Dec 2025, so for six weeks the newer version was visible to reviewers while the older one still governed. The review tool picks the version in force on the review date — 11 open MP-212 appeals were tested with the wrong one.
Renee presses “Re-test all 23”. The checker reads 347 open appeals and their dates of service, finds 23 that used a later version across four policies — lumbar fusion, the sleep apnea nerve stimulator, total knee arthroplasty and hereditary cancer gene panels — and re-tests each one criterion by criterion. Nineteen meet the criteria and get overturn drafts; four still do not, each with the reason. The 214 unappealed claims with the same mistake go to claims for reopening.
“23 appeals re-tested with the version in force — 19 met the criteria, sent to physician reviewers.”
The notice of reconsideration says the decision first — “We have changed our decision. We will pay for your surgery.” — then each reason with its source: the 2025 policy, the therapy discharge on page 31, the X-ray report on page 18, the waiver of liability. Reading level grade 7.4, English and Spanish versions, every reason cited, 5 of 5. Her phone calls are answered separately, as G-26-01182.
Dr. Whitcombe, orthopedic surgery, reads the story and the letter. Before the sign button works, the solution checks he is a physician in the right specialty and was not involved in the first decision, made by Dr. Lewis Haddad. He confirms he reviewed the complete file, enters his password and signs: overturn in full, on day 14 of 60.
“I reviewed the complete file, including the records sent with the appeal, and I was not involved in the first decision.”
G-26-01182 is on day 14 of 30, due Wed 28 Oct. What we found: of Gloria's three calls, the first two were told “in review” correctly; on 24 Aug she was told “in review” after the claim had been denied on 20 Aug, because the service screen showed it as pended until the 27 Aug batch. The reply is drafted in plain language, and says what was fixed.
The same case, seen by the five people who carry it — what their day looked like, and what it looks like now.
Seven agents rebuild each appeal as a cited story and re-test the denial against the policy in force on the date of service; a physician reviewer signs.
Reads every letter, call note and portal message; separates appeals from grievances, sets the case type — expedited, Part B drug, standard pre-service, payment, grievance, expedited grievance — and starts each clock.
Pulls the original claim or request, the medical records received, the reviewer notes, the denial notice and earlier cases, and lays every event on a timeline with its date and source page.
Reads each document sent with the appeal, compares it with the original file, and marks each fact new or already in the file — citing the page in both places.
Finds the medical policy version in force on the date of service, re-tests the first decision criterion by criterion, and every morning runs the same check across every open appeal.
Drafts the decision letter at grade 8 or lower in the member's language — the decision first, then each reason with its criterion and evidence page; for upheld cases, the independent review case file.
Computes every case's time left each hour, warns the owner, proposes extensions only for listed reasons, and forwards upheld cases to the independent review entity before the deadline.
Groups decided appeals by policy, service, reviewer, version and overturn reason each month, and writes a short finding with the evidence for the medical policy committee.
Not part of the first decision; decides and signs. The agents propose; a named person decides.
Nurses, reviewers and coordinators can ask about any appeal, grievance or medical policy — or tell it what to change.
Why was Gloria Trevino’s fusion denied?
The denial used the wrong version of the policy. It cites MP-212 version 2026.1, criterion 2 — 12 weeks of supervised therapy. Her surgery was on 16 December 2025, when version 2025.2 was in force and asked for 6 weeks. She had 9 weeks, 17 visits. The review tool chose the version by review date.
Which other open appeals used the wrong policy version?
23 open appeals across 4 policies were tested with a 2026 version for a 2025 service: MP-212 lumbar fusion 11, MP-087 sleep apnea 5, MP-145 knee replacement 4, MP-301 gene panels 3. I am re-testing all of them now against the version in force on each date of service.
Which appeals could miss their clock this week?
Three need you first: A-26-04452 Raymond Castellano — expedited, hour 26 of 72; new therapy notes meet MP-118. A-26-04459 Herbert Galloway — Part B drug, day 4 of 7, no extension allowed; records requested twice. A-26-04455 Talia Moreno — Medicaid, day 25 of 30.
Draft the grievance reply for Gloria
Drafted for G-26-01182. On 24 August she was told her claim was “in review”, but it had been denied on 20 August; the service screen showed it as pended until the 27 August batch. The reply apologizes, says what was fixed, and points to her appeal, due 27 November. It is due by 28 October.
13 screens from the working solution, on its sample data. Pick one to see it large.
Clocks, reviewers, the policy date rule and what the agents may do are settings — changes are versioned and audited.
| Setting | Default | Choose from |
|---|---|---|
| Expedited reconsideration | 72 hours | +14 days, listed reasons |
| Part B drug | 7 days | No extension |
| Standard pre-service | 30 days | +14 days, listed reasons |
| Payment | 60 days | No extension |
| Grievance · expedited grievance | 30 days · 24 hours | +14 days with written reasons; none for expedited |
| Test denials against the version in force on the date of service | On | On · Off |
| Send upheld cases to the independent review entity automatically | 12 hours before the deadline; 4 hours for expedited | On · Off |
| Plain-language letters | Grade 8 or lower | English and Spanish; large print on request |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample health plan data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (KFF, Medicare Advantage prior authorization determinations in 2024, Jan 2026 — 80.7% of appealed denials overturned, fully or partly; HHS-OIG OEI-09-18-00260, 2022). Clocks per 42 CFR 422.590 and 422.564. People, plans and providers named on this page are fictional — characters and sample data in the working solution.
Software a health plan uses to take each appeal or grievance from the request in, through review, to a decision and letter inside its regulatory clock, with every step recorded. Appeals & Grievances Management adds agents that sort each letter, rebuild the original file as a cited timeline, mark what is new and re-test the denial against the right policy version.
The policy version checker finds the medical policy version whose effective dates include the date of service, compares it with the version the first decision used, and re-tests each criterion against the records with a citation. Every morning it runs the same check across every open appeal.
Yes. A physician reviewer with the right specialty who was not part of the first decision signs every medical-necessity appeal; the solution checks eligibility before the sign button works. Agents read, cite and draft — they never sign, send or extend a clock.
The intake sorter splits it out into its own case with its own clock — 30 days, or 24 hours when it is about a refused or extended expedited case. The appeal stays on its own clock, and the grievance specialist gets the call history and a drafted reply.
Expedited reconsideration 72 hours, Part B drug 7 days, standard pre-service 30 days, payment 60 days, grievance 30 days and expedited grievance 24 hours, following 42 CFR 422.590 and 422.564. Upheld cases are forwarded to the independent review entity automatically, 12 hours before the deadline or 4 hours for expedited.
Plain language at grade 8 or lower, in English and Spanish, with large print on request. It gives the decision first, then each reason with its criterion and evidence page, then what happens next. Uncited text blocks sending.
Your intake channels, the claims and authorization system, medical records, the medical policy library with every version, the member services call log, and submission to the independent review entity.
The Agentic Solution Engine builds and deploys it from your requirements — your clocks, medical policies, letter templates and a sample of decided appeals — and it goes live once every quality gate has passed. We will walk you through it on your own appeals first.
Every criterion shown met or not met, with the page that proves it.
1-min demoUtilization Management AutomationNo missed 72-hour or 7-day deadline, and the yearly metrics from the same data.
1-min demoMedical Policy SearchThe criteria that apply, with the policy section and version that say so.
1-min demoWe’ll run Appeals & Grievances Management on a sample of your own decided appeals.