Leveraging Utilization Management to Control Costs and Ensure Quality Care

Dealing with appeals and grievances is one of healthcare’s biggest challenges.

You’re juggling compliance risks, mounting operational costs, and the satisfaction of your members awaiting critical healthcare decisions. With regular changes in CMS standards and costs skyrocketing, manual appeals and grievances processes won’t cut it anymore.

By harnessing the power of Salesforce, digital transformation unlocks an intelligent appeals platform that drastically cuts operational costs, complies with CMS regulations, and ensures factual appeal decisions.


High operational costs, avoiding penalties for non-compliance, and maintaining member satisfaction


A platform that unifies submission data regardless of channel, standardizes workflows, integrates data, and provides robust reporting


Lower operational costs, continuous improvement driven by data, higher member satisfaction, and compliance with CMS regulations

Solving the Use Case


First of all, we generally configure four role and permission sets in Salesforce to achieve this use case. They are:

These roles will be used throughout a high level CAG flow that we customize in Salesforce Health Cloud. These are:

In the next sections, we'll explain how we configure Salesforce to optimize the process across every stage.

Meeting the Requirements


Members or providers have different preferences for submitting complaints, grievances, and appeals. Typically, they expect (and we configure) the following channels:

Although some of these options are outdated, we configure integrations to mitigate as much manual data entry as possible. For physical mail, we set up workflows that scan and create case objects with any relevant data. This case may be linked to the original member record, and addition information can be imported from the EHR.

For submissions over the phone, we utilize Amazon Transcribe or Contact Lens for Amazon Connect for Service Cloud or Health Cloud. This allows real-time transcription, meaning that appeals representatives don't need to manually enter data.

Faxes can directly create records and match existing member records in the EHR or CRM.

Case Creation and Routing

During case creation, appeals specialists typically have to manually enter details from appeals, complains, or grievances to route them to clinical review. This process has many risks for human error, and causes operational overhead.

However, the process can be improved in Salesforce.

We strive to make case creation as automated as possible, regardless of channel. This means that we generate as much data on a record without manual data entry.

To reduce manual data entry, we configure rules that route appeals to appropriate clinical resources based hours, skills, line of business, or other criteria. This is where Salesforce's declarative workflows allow for unprecedented flexibility.

Declarative Salesforce flows allow us to deliver the right priorities, to the right stakeholders, at the right time based on SLAs, member condition, and other details on the case. This takes guesswork out of case delegation.

Decision and Communication

We create a central Salesforce dashboard for this step. Key stakeholders are able to factually review each case – and decide to uphold, overturn, or flag for peer review – from a single dashboard that consolidates information required to determine medical necessity.

Once a decision is made, we use Salesforce's workflows to communicate authorization closure via email to providers and members. This ensures consistent, prompt, and thoughtful responses.

Responses are customized based on decision type, condition nature, and relevant data, reducing complaints, grievances, and appeals.


Mitigate risk with built-in reporting and issue alerting


Streamlined workflows automate case routing and decision communication

Less Manual Tasks

Eliminate manual effort with automated intake and data population, regardless of channel

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