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CMS Compliant Appeals, Grievances and Complaint Management System

Highly Customizable and Configurable System

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  • 360 degree Case Visibility
  • ODAG/CDAG CMS Universe Reporting
  • Realtime Dashboards
  • CMS approved bi-lingual Member Correspondence
  • Provider Dispute Resolution
  • Integration with Provider and third Party Appeals

Wipro's Appeals and Grievances System (AG360) is highly customizable and configurable module that helps Payers eliminate manual process, improves Compliance, automate correspondence, create the required reports, improve member satisfaction and in turn improve STAR rating.

AG360 is a modular SaaS web platform that streamlines the appeals and grievances life cycle by identifying processing and tracking cases at each stage of the process. The system provides the ability to prioritize cases, set up stringent turnaround time and configurable alerts to ensure timely outreach.

Using AG360, Health plans can generate regulatory and Universe reports. The highly customizable user-friendly dashboards assist the users with insights and helps in decision making.

The system will generate customized letters for members/providers/authorized representatives and stores them within the record for audit and compliance purposes. The metrics can be tracked for case processing, compliance, audits, and process improvement.

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End to End Appeals and Grievances Management System


Members Supported


Cases Handled


Cases resolved within time limit


A Comprehensive Appeals, Grievances, and Complaint Tracking System

Automated Correspondence

Issues the required letters to the member and stores them within each record

Complaint Tracking Module

Tracks the cases at each stage of the process to ensure plans remain compliant

Interactive Dashboard

Configurable and insightful dashboard to empower better decision making

Improved Star Rating

Faster turnaround times corresponding to key areas of performance to enhance member experience

Regulatory Reporting

Automation of A&G processes and generation of Part C and D Universe Reports as per CMS requirements

Audit Preparedness

In-depth reporting, tracking and analytic capabilities for reconciliation process and mitigation of risk exposure

Appeals, Grievances & Complaints

A Comprehensive Solution

Ensure Compliance

Maintain 100% regulatory compliance and deadlines by preconfigured workflows and automated notifications

Timely Resolutions

Eliminate time consuming administrative tasks by automated processing of standard and expedited cases.

Member Satisfaction

Enhance member experience by timely and accurate correspondence and reaching the right resolution.

Valuable Data Insight

Duplicate or previous case detection offers insights to the health plans for quick case resolution.

Reduce Cost

Elevated efficiency, streamlined workflows and faster workaround times lowers the operational cost considerably.

Minimize Risk

Highlighting potential non-compliance areas, potential audit findings exposes potential risk in real time.


Automated homegrown A&G system for a large National Health Plan

Integrated Solution

Automated and transformed the Membership management of a prominent Health insurer

Wipro provided an enterprise solution to handle both Medicare and Medicaid memberships with a unified top to granular view of the Membership financials.
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CMS Compliance

Managing and Transforming a BCBS Organization in Caribbean

Implemented edit logic that includes CMS and MA specific requirements to meet CMS regulatory mandates and timelines.
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Impact of CMS CDAG on Medicare Advantage Organizations

CMS conducts various audits on the health plans that sell health insurance products and provide star ratings based on the plan's quality and performance.

The CMS audit program includes multiple areas— here the focus is on CDAG: Part D Coverage Determinations, Appeals, and Grievances, how CMS oversees this process and the impact it has on the health plans' star ratings.

Denials on PART D Coverage directly impact beneficiaries


Accurate and timely reconciliation of medicare enrollment and payments

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Integrated Health Risk Assessment Solution

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