When a claim is denied, the appeals and grievances process is what gives members a way to ask for a review and make sure the right outcome is reached. On the surface, it’s about fairness and compliance. In reality, it’s one of the more complicated and resource-heavy workflows payers have to manage. There are multiple steps, tight deadlines, and very little room for error.
Every payer has to follow strict CMS rules for how quickly they acknowledge and resolve each case. Missing even one of those timelines can mean more than a fine; it can affect STAR ratings, satisfaction scores, and the trust members place in their plan. The work behind the scenes is intense: gathering documentation, verifying data, confirming who’s authorized to appeal, and keeping the right clock running from day one. When any of those steps break down, the member experience suffers.
Some organizations have tried to solve the problem with RPA tools or custom-built apps, but most are still juggling manual processes and disconnected systems. Each fix tends to add new complexity instead of solving it. Without a single workflow that ties everything together, payers struggle to track progress, prevent duplicate cases, and keep a clean audit trail when regulators ask for proof.
Modernizing A&G Through Intelligent Automation
AI and automation can simplify this landscape. By using the same document intelligence capabilities that transformed referral management, payers can now read and classify incoming forms, whether handwritten or digital, and automatically identify whether a case is an appeal or a grievance. These AI skills help ensure that the right compliance clock starts immediately, deadlines are enforced, and documentation is tracked through every review level.
This orchestration extends across intake, routing, and communication, capturing everything from representative validation to duplicate control and evidence tracking. It’s designed to handle the full lifecycle of an appeal or grievance, so that every submission, amendment, and decision is visible, traceable, and audit-ready.
Integrating these capabilities with an orchestration platform like ServiceNow enables payers to automate intake, route cases to the appropriate reviewers, and manage notices with full audit trails. It also eliminates the need for multiple third-party tools to handle transcription, data extraction, and communications. The result is a single, consistent view of each case and every decision, from intake through external review.
The ROI Beyond Efficiency
Appeals and grievances might not seem as exciting as other digital transformation use cases, but the business impact is undeniable. Automation reduces duplicate cases, manual touches, and turnaround times, while also mitigating risk. In one three-year model, an A&G team of ten full-time employees could achieve roughly a 30% faster case resolution rate and reduce external review escalations. For plans that pay hundreds of dollars per independent review, those savings add up quickly.
Equally important are the intangible benefits: fewer late decisions, more consistent communications, and greater member trust. Public CMS and OCR actions can erode confidence among brokers and employer groups, which can have long-term consequences for enrollment and reputation. Enforcing timelines, maintaining audit-ready documentation, and ensuring fairness throughout the process not only protect against penalties but strengthen relationships with members and partners.
Reputation and Risk Go Hand-in-Hand
The cost of a poor appeals and grievances process goes far beyond penalties. Every missed deadline or inconsistent decision chips away at the trust that members, brokers, and employer groups place in a health plan. These relationships are fragile, and once confidence erodes, it can take years to rebuild. For organizations that depend on STAR ratings and quality scores, such a loss of trust quickly becomes a business issue.
The reputational risk is often greater than the financial one. Late or incomplete notices can make their way into public reports and feed negative perceptions among consumers and partners. Brokers and employer groups want to represent plans that resolve issues quickly and treat members fairly. When those expectations are not met, they look elsewhere.
Addressing this requires transparency and consistency. Automated enforcement of timelines, clear communication templates, and visibility into decision trends show regulators and members alike that a plan is accountable. Turning appeals and grievances into a structured, data-driven process not only mitigates penalties but also restores credibility.
A Platform Approach to Compliance and Trust
For payers who already use ServiceNow, integrating A&G into the platform helps rationalize redundant tools and consolidate workflows into a single, governed system. For those new to ServiceNow, it creates a compelling business case to adopt an enterprise platform that delivers measurable ROI while reducing compliance risk. Either way, the value extends beyond operations. It’s about accountability, transparency, and trust.
Appeals and grievances are a reality of healthcare administration, but they don’t have to be a burden. With AI-powered orchestration and compliance-ready workflows, payer organizations can turn one of their most complex processes into a source of clarity, confidence, and lasting member satisfaction.
That shift, from reactive compliance to proactive excellence, is what ultimately defines a modern payer organization.
