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Member Experience / A&G Management

Healthcare Appeals and Grievances Case Management System

Automate case intake, achieve faster case resolutions, ensure effortless compliance with a comprehensive appeals and grievances management solution.
Inovaare_Appeals and Grievances Case Management System

What we solve

Key challenges

Every case matters. One delay or error can lead to audit findings, penalties, and lost Star Ratings. A&G leaders operate under constant scrutiny and have a direct impact on compliance, reputation, and revenue. Yet many are stuck with disconnected tools and reactive processes. Some of the major concerns being:

Time-consuming processes

Compliance issues

Disconnected systems

Lack of transparency

How we solve

Redefine Appeals and Grievances Management

Our Appeals and Grievances Case Management Solution directly addresses these critical issues by leveraging advanced AI and automation. The solution streamlines time-intensive workflows, ensuring faster, more accurate resolution of cases while maintaining full regulatory adherence. By automating manual processes, it significantly reduces the risk of human error and mitigates costly penalties.

Why Inovaare

Healthcare native, payer trusted

Our A&G solution brings control, speed, and confidence to one of the most high-stakes functions in healthcare operations.

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.

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One-click report generation

Instantly generates compliant reports and universes, eliminating errors and delays.

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Workforce management

Tool to track and assign cases, and balance workload and capacity in real time.

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Letter management

Auto-generates and tracks member and provider letters with version control.

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Centralized dashboards

Real-time visibility across teams, cases, and performance metrics.

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Global communication hub

Central hub for communication with internal teams and external vendors.

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Real-time audit logs

Automatically logs every action taken on and every task assigned for a case.

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Task tracker

Tracks key due dates, triggers alerts, and helps avoid NMPs for regulatory deadlines.

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AI Agent–driven case intake

Autonomous AI agents classify, assign, and initiate cases automatically.

Engineered for Compliance. Designed for Efficiency.

Our products

We offer products purpose-built to enhance compliance, streamline audits, and improve A&G performance. Whether bundled into the platform or used standalone, our solutions deliver real value across the entire appeals and grievances lifecycle.

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.

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Inovaare_A&G Universe Generator & Scrubber

A&G Universe Generator & Scrubber

Automatically generate CMS-ready audit universes that meet formatting, logic, and regulatory requirements, without manual cleanup.

IRE Package Manager

Generate complete, compliant IRE packets quickly and accurately, ensuring every case sent to MAXIMUS meets CMS documentation standards.
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Inovaare_Complaint Tracking Module

Complaint Tracking Module

Track, triage, and resolve member complaints in one place, connecting upstream issues to downstream action with full visibility.

QIO Appeal Management

Manage QIO-level appeals with confidence using workflows purpose-built for federal quality improvement timelines and submission requirements.
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Agentic AI and Analytics

Layer intelligence into your A&G operations, detect patterns, predict risk, and surface operational blind spots with AI agents and GenAI summaries.

Success story

Outcomes that matter in A&G

It’s not just about staying compliant, it’s about resolving faster, working smarter, and reducing effort. Health plans using our A&G solution are seeing real impact. One California plan cut resolution times, reduced manual workload, and reported zero audit findings.
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Annual operational savings ($)
$ 0
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Less resolution time
0 %
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A&G-related findings
0
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Leadership/IT monthly hours saved
0

Related products

Amplify your A&G process

Resources

FAQs

Have questions? We have answers.

Regulatory Compliance

How does Inovaare’s A&G solution keep us compliant?

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.

How does the system handle regulatory updates?

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

Is pricing based on user licenses or case volume?

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.

Are implementation and support included in the pricing?

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.

How long does setup take?

Most implementations are completed within weeks, not months. Our prebuilt templates and rapid deployment framework minimize disruption and deliver faster time-to-value.

What level of support does Inovaare provide?

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

How does Inovaare’s A&G solution impact cost efficiency and ROI?

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.

Does Inovaare require heavy IT involvement post-implementation?

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

Can Inovaare integrate with our existing EHR and claims systems?

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.

Is Inovaare’s A&G platform cloud-native?

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.

Does Inovaare support no-code or low-code configuration for workflows?

Yes. Our self-service platform empowers users to configure rules, routing, templates, and workflows without developer support, reducing IT dependency and increasing agility.

How secure is data integration with Inovaare’s A&G platform?

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.

What infrastructure or hosting model does Inovaare follow?

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.

Can AI agents be customized for our specific A&G processes?

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.

Does the A&G solution support Agentic AI architecture?

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.

Can the A&G solution be deployed on-premise?

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.

How does the A&G solution stay current with evolving technology?

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.

Explore our AI-driven healthcare solutions

Struggling with compliance burdens, operational delays, or data gaps?

Discover how Inovaare’s SaaS-based payer solutions, built on its AI-powered platform,
help health plans streamline processes, reduce risk, and improve member outcomes.

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