Appeals & Grievances Solution The Centers for Medicare & Medicaid Services (CMS), Medicare Part C and D Oversight and Enforcement Group (MOEG) is responsible for conducting program audits for Medicare Advantage (MA) and Prescription Drug (Part D) plans (plan sponsors) to ensure compliance with CMS requirements. In past few years, CMS audit results �ind numerous �inding in healthplan’s Appeal and Grievances operation. Without a comprehensive software platform, it has been dif�icult for Plan sponsor to meet various requirements from CMS and NCQA. What Inovaare offers Inovaare’s Appeal and Grievances software solution has incorporated the CMS and other regulatory requirements that will assist you in monitoring, auditing, and overseeing your organization’s A&G operations, with the aim of achieving better performance outcomes and ultimately enhancing service delivery and ensuring better coverage for bene�iciaries. Business Bene�it Ef�icient Process Centralized Information Reduced turnaround time Enforcement of operational polices CMS Compliant Timeliness of case processing Letter generation Appropriate case review Audit Ready CMS audit support Data validation support Internal audit support Quality Improvement NCQA measure tracking CMS Star rating Trend analysis Appeals & Grievances Solution The solution has two major modules A&G Process Manager The process manager automates and streamlines Part C and D Pre Service Appeal, Post Service Appeal, Grievances and CTM processes starting from Issue intake, Issue Investigation, Closure to External Processing - IRE, ALJ, MAC etc. Features Pre-built meta data & work�low Pre Service Appeal Post Service Appeal Grievances External Review Process - IRE, ALJ & MAC A&G Analytics Dashboard Correspondence Tracking The Analytics dashboard provides comprehensive view of adherence to compliance, quality management requirement, Operational SLA, IPA oversight and trend analysis on various categories. It also includes out of box regulatory reports – CMS Universe, Star Ratings, Part C and D reports. Reports & Dashboards Letter generation Member communication tracking Provider communication tracking Operational reports CMS Compliance reports CMS Star and NCQA reports Trend Analysis dashboards IPA Oversight Alerts & Noti�ications Timeliness monitoring for standard & expedite case User de�ined alerts & reminders Turn Around Time tracking Technology Secured private cloud deployment Role based access control 3rd party integration engine Admin console for process con�iguration 2015 Inovaare Corporation. All rights reserved. For more information, please visit us online at www.inovaare.com or call us at 408-850-2235 c