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Eliminate A&G Backlogs.
Hit Every SLA. Cut Staffing Costs 40–60%.
AI-driven intake-to-determination workflow that meets every CMS and state SLA while dramatically reducing operational cost.
What Are A&G AI Agents?
A&G AI Agents handle the complete intake-to-determination lifecycle for appeals and grievances. From any channel call, fax, mail, portal, or handwritten letter the agents auto-classify, verify AOR, stamp receipt dates, triage expedited cases, and create fully documented cases in under 2 minutes.
They automate all mandated communications, assemble comprehensive clinical summaries from prior auth, claims, care management, and medical records systems, and generate evidence-based decision recommendations with confidence scoring all while maintaining a 100% timestamped audit trail for CMS and EQRO reviews.
Our Appeals & Grievances AI Agents
Intake Agent
Receives appeals and grievances from any channel — call, fax, mail, portal, handwritten letter. Automatically identifies type (Appeal vs. Grievance vs. Inquiry), verifies Authorization of Representation (AOR), stamps the receipt date including weekends, checks for expedited status immediately, and creates a fully documented case in under 2 minutes. Sends acknowledgement letter and requests missing documents via omni-channel outreach.
Replaces a 40-minute manual process with 95% automation. Every case is compliance-ready for both MA and Medicaid audits — timestamped, classified, and AOR-verified without a single manual step.
⚡ 95% Intake Automation — 40 min → 2 minOmni-Channel Notification Agent
Automates all mandated member and provider communications throughout the A&G lifecycle — acknowledgement of receipt within 5 days, missing document requests, and final decision notifications. Delivers via mail (multi-language), SMS, email, and conversational AI calls. Ensures every mandated touchpoint is compliant, timestamped, and audit-ready for CMS and EQRO review.
Eliminates manual calling and letter generation for every notification touchpoint. Saves 75% of staff time on administrative notifications while guaranteeing zero missed acknowledgement deadlines — with full state override support (e.g., CA 30-day grievance cap vs. federal 90).
⚡ 75% Staff Time Savings on NotificationsClinical Summary Agent
Aggregates data from prior authorization, claims, care management, and medical records systems to generate a complete clinical summary for every A&G case. Eliminates the need to manually navigate multiple systems and ensures all relevant clinical evidence is compiled in one place.
Reduces data gathering time from hours to minutes while ensuring completeness and audit readiness of every case before review.
⚡ Faster Case PreparationA&G Decision Agent
Generates evidence-based decision recommendations with confidence scoring for clinical reviewers, aligned with regulatory timelines for standard and expedited appeals and grievances.
Improves decision consistency and reduces review time by up to 70%, while maintaining human-in-the-loop clinical oversight for final approvals.
⚡ 70% Review Time SavingsEnd-to-End AI Workflow
Why Health Plans Are Moving Now
- 7-day standard / 72-hr expedited decision mandates (§422.568 / §438.210)
- CMS-0057-F: Prior Auth API and reduced timelines now required
- Auto-approval triggered if plan misses decision deadline
- State regulators auditing UM SLA compliance with increasing frequency
- 40-min manual intake × thousands of requests = massive bottleneck
- Clinical reviewers spend hours gathering evidence before determination
- SLA failures erode provider relationships and Star ratings
- Missed GoldCarding opportunities = unnecessary clinical review cost
- Intake-to-case in 2 min any channel — 95% automated
- AI evidence assembly replaces hours of manual data gathering
- Custom GoldCarding + auto-approval rules reduce unnecessary reviews
- 40–60% total staffing reduction with improved turnaround times
Where Appeals & Grievances Agents Shine
Resolving Member and Provider Requests Efficiently
Appeals Intake & Triage
Clinical Evidence Summarization
Decision Recommendation & Confidence Scoring
Mandated Notification Automation
CMS & EQRO Audit Readiness
Multi-Language Omni-Channel Delivery
Case Routing & Escalation
AOR Verification & Expedited Triage
Star Rating & CAHPS Protection
Medical Necessity Review Support
Ready to Transform Your A&G Operations?
Request a personalized analysis see exactly what CareInsight saves your plan.
Ready to Transform Your A&G Operations?
Request a personalized analysis see exactly what CareInsight saves your plan.
