AI-Powered Healthcare Appeals and Grievances Management
Streamline Appeals. Expedite Processing. Improve Outcomes.
Healthcare Appeals and Grievances Management, on ServiceNow
Modernize complex payer workflows with an AI-powered solution built natively on ServiceNow. KeenStack’s Healthcare Appeals and Grievances Management solution automates intake, routing, validation, and audit documentation so health plans can resolve faster, reduce compliance risk, and protect member trust.
Built for U.S. health plans and TPAs, the solution connects seamlessly with existing claims, clinical, and EMPI systems to deliver low-code agility, audit-grade traceability, and measurable ROI.
Addressing Critical Appeals & Grievances Management Challenges
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Delayed Member Resolution
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Inconsistent Documentation & Notices
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Operational Bottlenecks & High Touch Volume
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Lack of Unified Insights
Manual intake and routing of Appeals and Grievances lead to missed deadlines and prolonged case resolution.
Fragmented systems and manual processes cause variation in notice quality and increase compliance risk.
Appeals and Grievances workflows consume excessive operational resources, diverting focus from strategic improvement.
Siloed data and weak analytics limit visibility into overturns, timeliness, and root-cause trends, hindering continual process improvement.
Revolutionizing Appeals and Grievances Management with Advanced Features
Compliance
Automation
Enforce CMS timeliness rules, generate regulator-grade notices, and maintain a complete audit trail for every case.
Now Assist Case Validation
Now Assist automates Appeals and Grievances validation using knowledge article requirements to ensure compliance and completeness.
AI-Driven Intake and Routing
Automatically capture, classify, and route appeals and grievances across fax, email, and portal channels. The right clock starts on day one.
Document Intelligence for Intake Automation
Extract, process, and automate Appeals and Grievances intake with Document Intelligence for faster, more accurate case creation.
Audit-Ready Documentation
Use standardized templates, automated letters, and dashboards that make audits faster and error-free.
Coordinator Insights Dashboard
Coordinators view insights on Appeals and Grievances via Platform Analytics Dashboard for real-time visibility and performance tracking.
How It Works
Intake and
Validation
AI-powered document intelligence reads and classifies each submission, verifying completeness, identifying duplicates, and confirming representative authorization.
Workflow
Orchestration
Cases route automatically to the correct reviewers with built-in SLA timers and clock controls, ensuring compliance deadlines are met without resets.
Communication and Documentation
Generate acknowledgments, reminders, and determinations from standardized templates, creating regulator-grade letters and audit-ready packets.
Analytics and
Insights
Monitor timeliness, backlog, and overturn trends via the Platform Analytics Dashboard to drive continuous improvement.
Tailored Benefits for Every Role
Automated timelines and notices ensure audit readiness and eliminate CMS deficiencies.
Fewer manual touches, faster resolutions, and fewer external reviews.
Real-time dashboards to track workload, timeliness, and case outcomes.
Built natively on ServiceNow for secure data, low-code agility, and scalable automation.
Built on ServiceNow for Better Results
Together, KeenStack and ServiceNow empower payer organizations to streamline the Appeals and Grievances process, reduce compliance risk, and deliver faster, fairer outcomes for members and providers alike.
Frequently Asked Questions
What health plans want to know before modernizing their appeals and grievances process.
What is AI-powered healthcare appeals and grievances management, and why is it urgent for health plans right now?
AI-powered appeals and grievances management on ServiceNow automates the intake, classification, routing, and documentation of member appeals and grievances, so health plans resolve cases faster and stay ahead of compliance deadlines. The pressure behind this is building fast: Medicare Advantage plans processed 53 million prior authorization requests in 2024, and denial rates have climbed 35 percent since 2019. Right now only 1 percent of denied members appeal at all, but in prior authorization specifically that figure is already at 11.5 percent and rising, and members who do appeal win 80 percent of the time.
How much is unmanaged appeals and grievances volume costing health plans?
Each appeal costs an estimated 450 dollars to process once you account for coordinator time, clinical review, notices, and compliance overhead. At today’s prior authorization appeal rate alone, that’s roughly 470,000 appeals industry-wide, and if that rate climbs to 20 percent as members catch on, the industry cost jumps to an estimated 369 million dollars. Compliance exposure is rising just as fast: CMS issued more than 3 million dollars in civil monetary penalties in 2025 alone, more than the prior four years combined. For a deeper look at why the reputational cost often runs even higher than the financial one, see Untangling Healthcare’s Appeals and Grievances for Payers.
If we already have a claims or case management system, why do we need a separate appeals and grievances solution?
Your core claims and administration systems are built to be the system of record, not to orchestrate everything that happens around an appeal or grievance. KeenStack’s solution runs on ServiceNow alongside those systems, handling intake, classification, routing, and audit trail so nothing falls into a gap between departments. Your core systems stay the system of record. ServiceNow becomes the system of orchestration.
How does this solution help health plans keep pace with new CMS transparency and timeliness requirements?
CMS now requires Medicare Advantage plans to publicly report prior authorization denial and overturn rates, and recent rules have extended appeal windows and eliminated certain forfeiture provisions. KeenStack’s solution captures the case receipt date automatically at intake and maintains a complete, timestamped audit trail of every action taken on a case, giving compliance teams the documentation CMS auditors expect. Standardized templates and automated letters reduce the notice-quality variation that shows up in audit findings.
How does KeenStack use AI to process incoming appeals and grievances?
Document Intelligence reads uploaded appeal and grievance forms, whether they arrive as a fax, scan, or PDF, and automatically extracts the fields a coordinator used to type in by hand, including member information, claim number, denial reason, and provider details. Now Assist then validates that extracted data against your organization’s knowledge article criteria and automatically classifies each case as approved, awaiting information, pending representative proof, or rejected. This is the same Document Intelligence engine behind KeenStack’s healthcare referral management solution, applied here to a related but distinct payer workflow.
Take the Next Step Toward Smarter Appeals and Grievances Management
Experience firsthand how KeenStack’s AI-powered solution accelerates case resolution, strengthens compliance, and builds member trust through intelligent automation and real-time insights.