The Appeals & Grievance Agent turns disorganized case files into structured, reviewer-ready packets — with the key facts, issue classification, timeline, supporting evidence, and next steps assembled before a reviewer opens the case.
Faster
appeals and grievance case resolution
100%
of case documents structured before review
Zero
regulatory deadline gaps with automated tracking
Reads every file in the case and builds a clean summary with the issue type, key facts, timeline, relevant documents, and next steps — so reviewers can begin evaluating immediately.
Pulls policy language, prior authorization history, clinical documentation, denial rationale, benefit rules, and case notes into one citation-linked packet ready for reviewer action.
Flags missing information, approaching regulatory deadlines, and decision rationale gaps so health plans can stay compliant and avoid costly timeline violations.
Every case record includes the evidence cited, policies applied, and decision rationale captured — so every outcome can be defended with a clear, structured audit trail.
The Appeals & Grievance Agent reads every file in the case, classifies the issue, and builds a structured summary so reviewers can begin evaluating immediately — not after an hour of manual file organization.
Classifies each case as an appeal or grievance, clinical or administrative, and routes it with the correct issue type identified upfront.
Surfaces the regulatory timeline for each case — including key dates, decision deadlines, and any at-risk timeframes based on current case status.
Extracts the key facts: member information, the service or decision being disputed, denial reason, and dates of service — all organized before the reviewer touches the file.
Identifies next steps based on case type, current status, and any outstanding missing information so reviewers know exactly what action is needed.
The agent assembles a complete, citation-linked evidence packet for each case — drawing from policy documents, prior authorization history, clinical documentation, benefit rules, and case notes so reviewers never have to hunt for supporting material.
Relevant policy language is cited by source and version, matched to the specific issue type and coverage question in dispute.
Prior authorization history and original denial rationale are included automatically so reviewers have full context for every appeal.
Clinical documentation is organized and linked to the specific disputed service, reducing the time spent cross-referencing records.
Benefit rules and plan-specific criteria are surfaced alongside case facts so coverage determinations are grounded in the right plan language.
Appeals & Grievance Agent
Faster
100%
Zero
"Before CHAI, our appeals coordinators were spending most of their time just organizing files. Now they open a case and the summary, the evidence, the timeline — it's all there. They're reviewing, not assembling."
Jennifer Park
Director of Appeals & Grievance, Medicare Advantage plan, 310,000+ members
The Appeals & Grievance Agent delivers structured case packets directly into your existing systems — no manual file organization, no separate portal, and no changes to how your team reviews and resolves cases.
CMS and state-mandated appeal and grievance deadlines are tracked automatically and flagged when a case is approaching or at risk of a timeline violation.
Summary structure, evidence requirements, issue classification rules, and escalation logic are configured at onboarding to match your plan's appeals and grievance policies.
Everything you need to know about how the Appeals & Grievance Agent works and fits into your existing review operations.
