Transforming Appeals & Grievances

Quality improvement is talked about more and more across the healthcare ecosystem. Quality isn’t just the service provided, but the complete process of doing business. Managing the appeals and grievances process is not only about quick and accurate resolutions, but the quality of service when coming to a decision.

Kiriworks Appeals & Grievances (A&G) helps healthcare payers improve compliance, increase productivity, improve quality scores and boost member and provider satisfaction. Whether Medicare, Medicaid or commercial, the solution streamlines the appeals and grievances life cycle through automated processing, communication and reporting. Business rules are built on a plan’s (or state’s) regulatory requirements and guidelines. Cases are all prioritized based off a standard or expedited appeal or grievance and each stage of the process documents all internal and external communications. Universe reports are generated by the click of a mouse and additional reporting allows management greater process insight.

  • Medicare

    Universe: Pre-built CMS Universe tables that are automatically populated. Tables are easily searchable and can be exported to excel with the click of a mouse.

    Compliance: Helps adhere to CMS compliance deadlines and regulatory requirements along with intelligently requesting proper documentation throughout the appeals & grievances process.

    Data Submission: Ability to create and store quarterly data validation reports for annual submission. Easing the administration of reporting and audit preparation.

  • Universal A&G for Medicaid and Commercial payers

    Regulations: Configurable to federal and state regulatory requirements. Ability to use multiple Independent Review Organizations and designate the pattern in which appeals get assigned.

    Flexibility: Set individualized rules and activities per plan and/or state. Easily change and administer how cases are managed and processed. Modify rules, process guidance, SLAs and reports.

    Reporting: Ability to customize reports based on plan and/or state guidelines with specific classification and terminology, plan and plan level specific activities such as verbal acknowledgements, automatic extensions and/or priority review.



  • Maintain Compliance

    Adhere to compliance deadlines and regulatory guidelines to ensure timeliness of resolution and avoid fines and penalties.

  • Timely Resolutions

    Automated processing ensures timeframes of standard and expedited cases are managed correctly.

  • Central Repository

    Leverage existing member and claim data for real-time processing of cases.

  • Process Visibility

    Leverage dashboards to manage all cases, keep managers informed and avoiding bottlenecks within the process.

  • Real Time Monitoring

    Provides holistic view into expedited cases and automatically notifies correct parties of approaching due dates.

  • Improve Member Satisfaction

    Ensure members are provided the correct correspondence and notified in a timely manner of all decisions.

“The Appeals & Grievance solution designed by Kiriworks is one of the most innovative and configurable solution I’ve encountered. It has the ability to process any line of business and when calculating the ROI on this product, it is easy to see how the cross company usages of this product reveal it pays for itself in no time.”
Director of Appeals & Grievances, Gateway Health

DISCLAIMER: While Kiriworks healthcare payer accelerator products are designed to aid in the collection, management and reporting of business content, these products do not relieve users of responsibility to insure compliance with all applicable state and federal regulations and implement procedures to examine and verify for completeness and accuracy of all data and output before its use.