Healthcare scenario: Manage appeals
Available with: Microsoft 365 Copilot and Copilot Studio Scenario level:
KPIs impacted
Claims processing time
Value benefit
Cost savings
Using Copilot to manage appeals
1. Get requested appeal context
Use a Copilot agent to analyze requested appeal documents, medical records, and supporting documents such as clinical guidelines and policy terms.
Copilot Studio Agent
Benefit: Saves time for the appeal and grievances (A&G) Analyst and ensures critical information is easily accessible.
2. Gather pre-clinical research
Use a Copilot agent to summarize lengthy documents (analyzed in step 1) to create comprehensive case summaries, highlighting key points for review.
Copilot Studio Agent
Benefit: Assists A&G Analysts in understanding the case by providing relevant insights.
3. Share case information
Use Copilot Pages to generate a note to the A&G Analyst(s) outlining the summarized information. A&G Analysts can review/ refine the summary and add their insights and updates.
Microsoft 365 Copilot Chat2
Benefit: Enhances clarity and comprehension about the appeals, reduces time, leading to more accurate resolutions.
4. Decision-making support
Use a Copilot agent to analyze similar past cases, clinical guidelines, and policy terms to assist in decision-making.
Copilot Studio Agent
Benefit: Reduces the probability of human error by A&G Analysts by leveraging these insights.
5. Share resolution suggestions
Use a Copilot agent to generate resolution suggestions and provide a ranked list of suggestions with supporting rationale for each option with A&G team for comprehensive review.
Copilot Studio Agent
Benefit: Assist the A&G Analysts in consistent and accurate decision making.
6. Appeals documentation
Use Copilot Pages to maintain a durable record of all discussions, decisions, and supporting documents, which can be easily referenced in future appeals or audits.
Microsoft 365 Copilot Chat2
Benefit: Saves time creating documentation.
1Access Microsoft 365 Copilot Chat at m365copilot.com or the Microsoft 365 Copilot Chat mobile app and set toggle to “Web".
2Access Microsoft 365 Copilot Chat at m365copilot.com, the Microsoft 365 Copilot Chat mobile app or the Microsoft 365 Copilot Chat app in Microsoft Teams, and set toggle to “Work”.
3Copilot agents allow Microsoft 365 Copilot to access your organization-specific apps. In the past, this would have required an API call to get data from a system of record. The content in this example scenario is for demonstration purposes only. You should evaluate how Copilot aligns with your organization’s business processes, regulatory requirements, and responsible AI principles.
The content in this example scenario is for demonstration purposes only. You should evaluate how Copilot aligns with your organization’s business processes, regulatory requirements, and responsible AI principles.
