Processes

What will AGI do for Manage appeals and grievances?

A member, provider, or authorized representative submits a formal appeal against a coverage decision or a grievance regarding service quality.

Trigger: A member, provider, or authorized representative submits a formal appeal against a coverage decision or a grievance regarding service quality.
Outcome: A final determination is reached, the stakeholder is formally notified, and any required adjustments to claims or authorizations are executed.

The work itself

Grounded Work Profile

Receive and log the appeal or grievance submissionprocessProfile
Triage and categorize the request based on urgency and typeprocessProfile
Gather relevant medical records, policy documents, and prior claim dataprocessProfile
Conduct a clinical or administrative review by appropriate personnelprocessProfile
Render a final determination to uphold or overturn the original decisionprocessProfile
Generate and send formal notification of the resolution to the stakeholderprocessProfile
Execute necessary follow-up actions such as reprocessing claimsprocessProfile

How AGI delivers it

Services-as-Software
Get the professional outcome delivered as software, priced on results, not headcount.
Services.do
Autonomous Agents as digital employees
Hire a digital employee that does the job under earned, supervised autonomy.
Agents.do
Business-as-Code
Encode how your work runs, once, as software that executes itself.
Platform.do

Value flow

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