Skip to main content

Appeal

Suggest edit Updated on April 22, 2021

An appeal is a request for your health insurance company, the health insurance payers from the provider, or the patient to review a decision that denied an authorization.

To create an appeal case, in the Patient 360 profile of a specified member, click ActionsNewAppeal.

For more information about appeal case management, see the Pega Care Management Business Use Case Guide.

The following list describes items that are related to the Appeal Microjourney:

  • Data model
  • Rules for the list of sources in the appeal intake
  • Updating the number of expiration days based on category code
  • Updating the status based on the decision
  • Determine resolution correspondence template

Data model

In App Studio, you can view the data model for Appeal in Case types.

Click the Data model tab on the Appeal page.

Rules for the list of sources in the appeal intake

To create an appeal case in the Pega Care Management application, fill in the required details such as contact channel, urgency, requesting provider, member, and denied authorization list. Use the following rules to configure a different source based on your organization's requirements.

Key rules for the list of sources

Step in the intake an d rule nameRule typePurpose
Metadata

pyContactChannel

Property - Field value Source for the Contact channel drop-down list (CL:PegaHC-AGWork)
Metadata

Urgency

Property - Field value Source for the Urgency drop-down list (CL:PegaHC-AG-Work)
Select requesting provider

D_GetProviderList

Data pageSearches for the requesting or service provider
Select Member

D_MemberPresentFuturePol

Data page Searches for member policies. Member ID is the parameter.
Select prior Auth request

D_ListOfDeniedAuthorizations

Data pageSearches for denied authorizations from which you can choose for the appeal case. Member ID is the parameter.

FinalDisposition

Property - Prompt listSource for the Final disposition drop-down list. If you choose Uphold, then the Approved days, Status, and Reject reason fields are read-only. If you choose Overturn, you can edit the fields.

Updating the number of expiration days based on category code

After the intake is complete, appeals are routed to medical directors for review. During the review, if the appeal is approved, then the system captures CertificationIssueDate and CertificationEffectiveDate as system dates and CertificationExpirationDate based on the authorization type, for example inpatient or outpatient.

Use this decision tree rule to make updates to the expiration days based on the request type.

Rule for expiration days

Rule nameRule typePurpose
SetExpirationDaysDecision treeSets the number of expiration days based on the category code

Updating the status based on the decision

Based on the decision outcome, the status of the authorization is set. You can update the status of the authorization based on the authorization decision and the reject reason that you configured. For example, you could change Reject to Denied.

Rule for updating the resolution status

Rule nameRule typePurpose
ResolutionStatusdecision table Evaluates the resolution decision based on the authorization decision and the reject reason, if applied

Determine resolution correspondence template

Based on the appeal decision outcome, correspondence is sent to the respective parties. You determine the correspondence template by using a decision table.

Use the ResolutionCorr decision table.

Did you find this content helpful? YesNo

Have a question? Get answers now.

Visit the Collaboration Center to ask questions, engage in discussions, share ideas, and help others.

Ready to crush complexity?

Experience the benefits of Pega Community when you log in.

We'd prefer it if you saw us at our best.

Pega.com is not optimized for Internet Explorer. For the optimal experience, please use:

Close Deprecation Notice
Contact us