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Member Appeals & Grievances

Industry-leading Appeals & Grievances software ensures real-time compliance

Why the Largest Health Plans Trust Inovaare A&G Solutions

Effective oversight and management of Appeals & Grievances (A&G) can be challenging. Whether a Medicare, Medicaid, Marketplace or commercial healthcare provider, health plans must ensure their compliance procedures—as well as those of their delegated entities—are updated and ready for audit.

Inovaare’s industry-leading Appeals and Grievances software empowers compliance teams with end-to-end visibility of real-time data for accurate monitoring, better decision making and expedited resolutions. The platform also allows for Appeals and Grievances software configuration to meet rapidly evolving business and regulatory requirements.

Member Appeals & Grievances

ACHIEVE NO AUDIT FINDINGS TO IMPROVE STAR RATINGS
  • Solution built by industry leaders who oversaw Appeals & Grievances Departments
  • Compliance-driven workflows refreshed continuously to eliminate NONC risks
  • Leadership has real-time visibility into all issues, even while in meetings
  • Cloud-based solution allows for a remote workforce
  • A&G Specialists are more efficient, resulting in faster resolutions of grievances and appeals
  • Member-centric outcomes and enhanced member experiences improve Star Ratings

Key Appeals and Grievances Software Benefits

  • Perfect Regulatory Audits
    • Achieve no audit findings
    • Avoid penalties

    Improve Star Ratings

    • Increase revenue
    • Enhance member experience

    Elevate Operational Efficiency

    • Streamline workflows
    • Lower costs

    Ensure Compliance

    • Eliminate non-compliance (NONC) notices
    • Prevent civil monetary penalties (CMPs)

    Simplify Regulatory Reporting

    • Automate A&G processes
    • Generate regulatory reports and CMS universes with the click of a button

Appeals & Grievances Software Features

  • Configurable appeals and grievances processes for Medicare, Medicaid, Commercial, ACO, MMP, MSO and PACE lines of business
  • Real-time activity monitoring
  • Unique appeals and grievances tracking
  • Complex business rules supported
  • Adjustable rules to keep pace with changing business requirements
  • Regulatory requirements designed into the core
  • Effective adherence to compliance deadlines
  • Flexible workflow rules with multiple configuration options
Health Plan Solutions - Healthcare Payer Solution

Appeals & Grievances Software Packages

A&G Pro 30 and A&G Enterprise

Inovaare knows the world of Medicare, Medicaid and Commercial health plans from decades of hands-on A&G department oversight. This expertise resulted in an Appeals and Grievances software platform rich in features and it’s unparalleled in the market.

Inovaare created two Appeals and Grievances software packages to meet any health plan’s unique requirements: A&G Pro 30 and A&G Enterprise. For many health plans, A&G Pro 30 is an out-of-the-box solution that can be implemented within 30 days to lower operating costs and improve member experience. However, for payers who require more complex processes, A&G Enterprise can be customized to address each requirement.

Industry-leading Implementation

Experience how a turnkey Appeals and Grievances system can be implemented within 30 days.

  • Business-requirement documentation created by expert project-management team
  • Project timelines, clear deliverables and task owners ensure timely implementation within budget
  • Training team equips users prior to system launch
  • Knowledge base supports continuous learning

Standard and Advanced Support Ensure Onboarding Success

  • Clients can opt for standard support or upgrade to advanced support
  • Support processes are clearly outlined prior to system go-live date
  • System is continuously updated with the latest regulatory requirements

Benefits that simplify operations

Personalized Home Pages by Role
  • Configurable to optimize productivity
  • Auto-prioritized cases and tasks for agents
  • Urgent case alerts help ensure compliance
Dynamic Case Management
  • Single repository to support collaboration
  • 360-degree view of the member
  • End-to-end visibility for efficient issue resolution
Built-in Compliance
  • NONCs eliminated
  • Cases get closed properly
  • Automated emails or written notifications
Logical Workflows
  • Preconfigured workflows drive compliance
  • secure leader approval with 14-day extensions
  • AOR/WOL documents from invalid requestors
Auto-populated Letters
  • Selectable conditions for letters
  • Approval and publishing automation
  • Compliant letters generated 
Dashboard and Analytics
  • Intuitive dashboards for better decision making
  • Customized KPIs within a configurable platform
  • Analyze urgent issues, performance and reports

Add-on Modules

Manage and Track Member Incidents

Complaint Tracking Module

Mismanaged complaint tracking compounds member issues and, over time, it results in major operational and reputational damage. Inovaare's experts designed its Complaint Tracking Module (CTM) so that several cases for a member can be created at once using linking technology. The common information is passed to each case—which eliminates double or triple entry—so only the unique information for each case will need to be completed (i.e., categorized). It even enables compliance teams to download cases from the CMS Health Plan Management System (HPMS) and systematically upload required HPMS files, saving health plans significant time and effort.

Achieve compliance consistently

Quality Review

Operational auditing process helps to ensure 100% compliant cases before your next mock audit or real audit. This enhancement has several impressive features including an attestation process to confirm the recommended changes were completed.

Plan assignments efficiently

Workforce Management

A first of its kind solution delivering workforce management. Leaders can configure the system to auto-assign cases to different agents using an admin table. For example, new hires can be configured to skip a rotation as they get up to speed.

Improve resource management and ensure timeliness

Knowledge Management

Utilize a powerful knowledge base to expedite resolutions. This is your one-stop-shop for knowledge which would include your knowledge articles, best practice guides, policy and procedures, onboarding training materials, and ongoing training documents and videos.

appeals and grievances software
Ensure 360-degree view of Decision processes

QIO Appeals

QIO Appeals track and trend the issues being reviewed by the QIO department. The workflow starts with the Intake Step, which includes member and issue documentation. Next is the Review step—which includes the details of issue or treatment—and the final step is Case Closing, which includes the determination and effectuation. The system allows for decisions made by the QIO to be tracked at each step—from intake through closure—guaranteeing each decision rendered is executed efficiently.

Implement Dynamic case management workflows

Provider Dispute Resolution

CMS expects all Medicare Advantage Organizations (MAOs) and payers to resolve payment disputes with non-contract providers promptly and ensure payments are made in accordance with the law. CMS account managers have been instructed to closely monitor MAOs’ actions, in this regard, and will take compliance actions as necessary. Inovaare's cloud-based Provider Dispute Resolution (PDR) software allows health plans to track, trend and process provider disputes, which helps to eliminate any compliance actions taken by CMS. Efficiently manage the PDR process through innovative automation.

Mitigate Compliance Risk

Sales Allegations

Sales Allegations are hard to prevent and, in many cases, just as difficult to track, due to the many aspects required to ensure CMS compliance in health-plan investigations. The fact that CMS is relatively silent on the specific requirements around investigation and closure of sales allegations makes it even more difficult and confusing. While health plans can’t prevent these instances, Inovaare’s Sales Allegations module helps health plans to ensure complaints are investigated and closed properly, reducing non-compliance risk.