Member Experience / A&G Management
Healthcare Appeals and Grievances Case Management System
What we solve
Key challenges
Time-consuming processes
Compliance issues
Disconnected systems
Lack of transparency
How we solve
Redefine Appeals and Grievances Management
Why Inovaare
Healthcare native, payer trusted
End-to-end compliance
Prebuilt rules, real-time checks, and auto-generated universes keep you audit-ready, every day, not just deadline day.
Lower cost to serve
AI workflows and self-service tools cut turnaround time and manual effort, freeing teams to focus on impact.
Full visibility and control
Dashboards, rules, and reports are owned by business users, so operations move faster, with zero dependence on IT.
Member-first focus
Automated updates, accurate resolutions, and faster follow-ups improve satisfaction and protect Star Ratings.
Key features
Empower your A&G team to deliver outcomes
Move fast, stay compliant, and scale confidently with a healthcare-centric platform that combines regulatory intelligence,
AI-powered automation and user-controlled configuration to eliminate friction from A&G workflows.
One-click report generation
Instantly generates compliant reports and universes, eliminating errors and delays.
Workforce management
Tool to track and assign cases, and balance workload and capacity in real time.
Letter management
Auto-generates and tracks member and provider letters with version control.
Centralized dashboards
Real-time visibility across teams, cases, and performance metrics.
Global communication hub
Central hub for communication with internal teams and external vendors.
Real-time audit logs
Automatically logs every action taken on and every task assigned for a case.
Task tracker
Tracks key due dates, triggers alerts, and helps avoid NMPs for regulatory deadlines.
AI Agent–driven case intake
Autonomous AI agents classify, assign, and initiate cases automatically.
Engineered for Compliance. Designed for Efficiency.
Our products
A&G management
Effortlessly manage appeals and grievances! Automate workflows, reduce manual effort, and ensure timely resolutions. Improve compliance and operational efficiency while enhancing member satisfaction with seamless, accurate, and real-time tracking of appeals and grievances. ×
Member journey dashboard
Gain Comprehensive Insights into Member Journeys! Track every touchpoint and interaction across the member lifecycle, providing a holistic view that drives better decision-making. Identify trends, improve service delivery, and increase member satisfaction with detailed, actionable insights. ×
PQI & QIO
Ensure the highest standards of quality care with our Potential Quality Issue (PQI) & Quality Information Organization (QIO) solutions. Automate quality improvement processes, monitor performance metrics, and comply with regulatory standards. Drive continuous improvement in care delivery and outcomes, and maintain excellence in healthcare services. ×
Data scrubber suite
Our Data Scrubber Suite helps you maintain clean, accurate data for all your reporting needs. Automate data scrubbing processes to identify and correct errors, ensuring compliance with regulatory requirements. Improve data integrity, reduce risks, and enhance decision-making with reliable data. ×
Appeals and Grievances Management
Handle A&G cases with speed, accuracy, and compliance through an intelligent workflow engine that adapts to product line rules and regulatory timelines.
- Auto-triggers escalations, notices, and SLA alerts
- Enables complete audit traceability from intake to closure
- Member-level visibility across all cases and categories
A&G Universe Generator & Scrubber
Automatically generate CMS-ready audit universes that meet formatting, logic, and regulatory requirements, without manual cleanup.
- Built-in rules for format, logic, and regulatory compliance validation
- Flags missing or misclassified records that can trigger audit issues
- Minimizes CMS audit findings and rework cycles
IRE Package Manager
- Dynamically assembles case materials based on type and timeline
- Applies CMS formatting rules to each submission
- Reduces rejected packets and manual rework during IRE escalations
Complaint Tracking Module
Track, triage, and resolve member complaints in one place, connecting upstream issues to downstream action with full visibility.
- Captures complaints across all intake points
- Auto-categorizes complaints by type, severity, and product line
- Surfaces complaint trends to identify root-cause fixes
QIO Appeal Management
- Enforces QIO-specific clock rules and appeal stages
- Templates and notices aligned with QIO engagement standards
- Isolates QIO cases from standard appeal queues for clarity and control
Agentic AI and Analytics
- Generates executive-ready insights from unstructured case data
- Identifies repeat complaint triggers and SLA breach predictors
- Empowers compliance and ops teams with real-time audit insights
Success story
Outcomes that matter in A&G
Related products
Amplify your A&G process
Member Experience
Health Plan Marketing CRM
Member Experience
Health Plan Services CRM
Manage service requests, issues, and outreach programs efficiently to boost member satisfaction and retention.
Member Experience
Member Portal
Provide members with a secure portal with 24/7 access to health information, benefits, and service requests, to boost member satisfaction and engagement.Â
Member Experience
Call Log Scrubber
Scrub CRM data to identify cases that need to be expedited and transferred to the health plan’s Appeals and Grievances Department.
Member Experience
Member360
Member Experience
Potential Quality Issues (PQI)
Equip your health plans with the tools to proactively identify, manage, and resolve quality issues before they escalate.
FAQs
Have questions? We have answers.
Regulatory Compliance
Inovaare’s platform is built with real-time compliance tracking and pre-configured regulatory logic, enabling health plans to automate documentation, maintain audit-ready records, and avoid non-compliance penalties. It ensures every process—from intake to resolution—adheres to CMS guidelines.
Our cloud-based platform includes continuous State and Federal rule updates and audit templates, so health plans never fall behind on regulatory compliance. These updates are applied automatically, reducing the need for manual configuration or IT support.
Pricing & Implementation
Our pricing is flexible and aligned with your operational model. We offer both user-based and case volume-based pricing tiers, so you only pay for what you use, whether you’re a small plan or a national health insurer.
Yes. Our pricing includes implementation, onboarding, and ongoing support. No hidden fees. We work with your team to configure the solution to your workflows, compliance needs, and reporting requirements from day one.
Most implementations are completed within weeks, not months. Our prebuilt templates and rapid deployment framework minimize disruption and deliver faster time-to-value.
We offer end-to-end onboarding, configuration assistance, user training, and ongoing support. Our team ensures smooth adoption and continuous optimization tailored to your compliance needs.
Operations
Inovaare reduces the cost to serve by automating labor-intensive tasks, minimizing audit penalties, and improving staff productivity. Most clients experience up to a 67% reduction in compliance-related expenses within the first year, making it a high-ROI investment for financial leaders focused on operational savings.
No. The platform is built to empower business users through no-code configuration. IT involvement is minimal beyond initial setup, freeing up technical resources for strategic priorities.
Technology
Yes. Inovaare’s open API architecture ensures seamless integration with EHRs, claims systems, and core platforms, enabling unified data access across appeals, grievances, compliance, and audit workflows.
Absolutely. Inovaare is a modern, cloud-native platform built to scale with your health plan’s growth. It supports multi-region backups, continuous monitoring, and seamless updates.
Yes. Our self-service platform empowers users to configure rules, routing, templates, and workflows without developer support, reducing IT dependency and increasing agility.
Inovaare follows HIPAA and HITRUST-certified protocols for secure API-based integrations. All data in transit and at rest is encrypted, ensuring compliance with healthcare data security standards.
Inovaare is hosted on a secure, scalable cloud-native infrastructure with multi-region backup, automated updates, and 24/7 monitoring. It’s built for performance, reliability, and compliance with industry-leading standards.
Absolutely. Our AI agents are fully configurable. You can define rules, triggers, escalation paths, and compliance logic based on your internal workflows and regulatory requirements. The system adapts to how your plan operates—not the other way around.
Yes, our A&G solution is built on a modern platform that fully supports Agentic AI. This means your workflows aren’t just automated—they’re intelligent. Our AI agents can take actions independently across intake, review, resolution, and reporting. You don’t need to be an AI expert to benefit. Everything is pre-configured, secure, and designed to work within your compliance framework, giving your team more time to focus on high-priority work, not repetitive tasks.
No, our solution is cloud-native by design. This allows for faster deployment, better scalability, built-in security, and seamless updates. It also means you get continuous improvements and the latest compliance logic—without the burden of managing infrastructure.
Our platform is continuously updated to support the latest advancements, including AI, automation, and regulatory tech. It’s built on a modern, extensible architecture—so new features, smarter agents, and compliance updates are added seamlessly, without disrupting your operations. You get long-term value without needing to rebuild or re-implement.