Picture this. A case worker for a major health plan is overwhelmed with the number of appeals and grievances being assigned to her. Let’s call her Jane. Jane is worried that she might not be able to complete all of them within the time frame that the plan allows. She doesn’t want to miss any critical deadlines that might result in the plan being non-compliant with CMS regulations. Jane is in a tizzy considering the sheer volume of tasks that await her.
But wait… All’s not lost yet. AG360 saves the day! Jane can login to AG360 and take a look at the cases assigned to her. She will see a dashboard when she logs on that will show her which cases are assigned to her and how long they have been open. She can then drill down to the one she wants to work on.
So Jane starts working on a standard pre-service appeal. The member is appealing the denial of a medication he needs for his migraine headaches. Jane calls the doctor’s office and speaks with the doctor’s nurse. She gathers that the doctor does not want the member to take this medication everyday anymore, as he was doing previously. As it turns out, it is dangerous to take it every day. Instead, the doctor is prescribing a different medication that he thinks will help with the migraines. Jane notes all this information and updates the case. She starts working on all the letters that need to go out. AG360 has the letter templates for her. Jane needs to create and send the letters. But then her supervisor (we’ll call him Randy) alerts her about a new, expedited appeal that just came in. Jane needs to stop working on the first appeal and start working on the expedited appeal immediately. She tells Randy that she will get on the new case as soon as she finishes the letters. But Jane does not finish the expedited case by the end of the day.
The next day, when Jane comes into work and logs in to AG360, she sees an alert telling her that there is an Expedited Appeal that needs her attention. So she gets back onto that appeal right away, after she gets her coffee. This appeal is about a member who needs another MRI on his right knee, even though he just had one last month, which is why the health plan had denied the request. She consults with the doctor and health plan to see if they will cover another MRI.
Meanwhile, Randy has run some of the AG360 reports to get a broader view of what is happening. Randy has run the Dashboard report to see how much the caseworkers have on their plates. He has run the Universe reports to see if there are any cases that are missing key dates or any that are not CMS compliant. Randy goes over to Jane’s desk to speak with her about the expedited case and the other cases assigned to her. Jane tells him that she has the information about the cases and needs to enter it into AG360 and create the letters, and then she can start working on another case.
Randy’s team relies on AG360 to help them manage their appeals and grievances. They know that the tool will send them an email notification as cases are approaching their Due Dates so that they don’t miss anything and let a case go beyond its Due Date. They respond to the login time alerting when they have expedited cases because they know that these cases need to be worked on immediately.
Randy and his team use AG360’s powerful search engine to help them find cases that they have worked on before, cases for the same member, or cases of the same type or category that may help them with the case they are currently working on. Randy has saved searches that they reuse as user defined reports.
Randy runs AG360 reports often to get a higher view of open cases. Appeals and Grievance reports provide a case count of each type and list them out too. Universe reports can be used to show that his group is compliant with CMS regulations.
To know more about Wipro’s Medicare portfolio, please visit https://www.wipro.com/en-BR/healthcare/medicare-advantage-360-platform/
Reference and note
As per Medicare.gov, in the Medicare Advantage plan one can get Medicare benefits through Original Medicare or a Medicare Advantage Plan (like an HMO or PPO). If you have Original Medicare, the government pays for Medicare benefits when you get them. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Medicare pays these companies to cover your Medicare benefits.
Who can join a Medicare Advantage Plan?
You must have Medicare Parts A and B and live in the plan’s service area to be eligible to join. People with end-stage renal disease (permanent kidney failure) generally can’t join a Medicare Advantage Plan.
Annual Enrollment Period