Specialized Appeals & Grievances Workflow Automation
Built on ServiceNow’s platform capabilities to streamline both appeals and grievances through automated intake, validation, and classification.

Perform a preliminary review of inbound submissions to determine completeness.
Automatically identify whether the submission is an appeal or grievance based on the form’s selection fields.
Route incomplete records to the “Awaiting Information” queue for coordinator review.

Grievance Categorization and Cost-Share Labeling

Automatically label grievances that are cost-sharing related based on form selections.
Enable separate tracking of cost-sharing grievances for compliance and reporting purposes.
Display “Appeal” and “Grievance” counts separately on the dashboard.

Proof-of-Representation Validation

Introduce a new “Representative Proof Required” state to flag cases where an authorized representative (e.g., parent or guardian) is filing on behalf of a patient.
Coordinators can update the record once proof documentation is received.
Prevents further automated processing until proof is validated, ensuring compliance and authenticity.

Comprehensive Document Extraction and Management

Integration with ServiceNow Document Intelligence to extract data from submitted forms, including:
Member information, provider details, denial reason, claim number, and grievance details.
Support for additional documents attached to the record.
A new field (Supporting Document Attached) is checked, and all filenames linked to the appeal or grievance record are attached to the Appeal case record for reviewer reference.

AI Validation and Knowledge Article Integration

Integration with Now Assist to validate extracted form data against the ‘Standard’ or ‘Expedited’ Knowledge Articles.
Automatically determine if the record meets all required criteria:
- Approved (meets requirements)
- Awaiting Info (missing required details)
- Representative Proof Required (representation verification needed)
- Rejected (criteria not met)
Organizations can modify or expand the Knowledge Article to align with their internal policies or payer-specific appeal rules.

Expedited Case Identification and Prioritization

Automatically detect expedited cases based on the presence of any provider contact details (Name, Address, City, State, ZIP, Fax, or Phone).
Flag these records as Expedited for visibility and prioritization in the dashboard.
No SLA timers are applied; expedited designation serves as a visual indicator for high-priority cases.

AI-Powered Appeals & Grievances Dashboard

Displays comprehensive real-time metrics for operational monitoring:
- Received Appeals and Received Grievances – Total records processed by type.
- Approved Appeals/Grievances and Rejected Appeals/Grievances – Counts by outcome.
- Awaiting Info – Active cases missing data, grouped separately for Appeals and Grievances.
- Representative Proof Required – Displays all cases awaiting proof of representation before proceeding.
- Type Breakdown – Pie chart showing Denied Claim, Denied Service Not Yet Received, and Cost Share Dispute distributions.
- Processing Type – Bar chart comparing Standard vs. Expedited submissions.
- Decisioning State – Pie chart visual summary of all records by state (Approved, Rejected, Awaiting Info, Proof Required).
Provides clear segmentation of appeals vs. grievances, enabling coordinators and management to monitor performance, compliance, and workload balance.