Payer

A Comprehensive Cloud-Native Payment Integrity Platform

CoverSelf empowers Payers by providing a single, integrated, scalable, open, and transparent platform that simplifies and democratizes the payment integrity industry to eliminate payment inaccuracies and identify new savings opportunities. The Platform is easy to use and hyper-customizable, addressing payment inaccuracies using multiple approaches. Our Platform is built on cutting-edge technologies for faster release capabilities to avoid “Pay & Chase situations”.

Self-Directed Domain-Specific Platform

Designed with all the use cases that are essential for creating, managing, and updating the reimbursement payment policies for the Payment integrity domain.

Coverself - Cloud-Native Payment Integrity Platform

Built-In Industry code sets and policies

Pre-configured industry code sets and rules that are continuously auto-updated.

DIY or Delegate - the choice is yours to make

Configure policies and write your proprietary business rules using our exceptionally easy-to-use platform or simply delegate them to us.

Policy Management

Ideate, create, customize, manage, test & publish policies & scenarios within hours without losing your IP

Extendable to all healthcare LOBs

Pre-pay and post-pay capabilities across all healthcare LOBs

Robust Rules Library

We empower Health Plans with a fully customizable and comprehensive set of rules for auto-adjudication, coding & clinical reviews across facility and non-facility practices, developed by industry experts with a strong and dependable background.

Modular Package
‍

Complete flexibility to choose any library package or specific rules based on your needs.

All Healthcare Lines Of Business

Library for each line of business such as Medicare, Medicaid, commercial, ASO, and Self-insured plan

Complex Logic & All Claim Types

Complex logic such as MPR, Bilateral, and Duplicate Logic across different claims such as professional, facility, & DME.

Payer-Specific Library
‍

Configure or customize health plan-specific rules & homegrown code

New Savings Opportunities

A platform that empowers domain experts to ideate, create, validate, test, and implement rules and new concepts on the fly without high technical dependency. Powered by our domain-specific language, CREOL^TM

“What If” Scenario

You’ll have the ability to identify & create new savings opportunities and then test their impact on historical claims data. Create proprietary policies faster.

Impact Analysis

Measure Rules Edits vs Savings at various thresholds prior to finalizing and publishing a customized rule

Speed to Release

Innovate and customize new product lines based on varied customer needs with the power to release quickly, anytime.

Data Mining and Analysis

Create scenarios to identify any anomalies without the need for technical teams. Pull claim fields to find patterns with SME’s innate knowledge.

Playground for SMEs

SMEs are equipped with the power to play and try out different concepts.

Query

Query across different claim data fields and in combination, quickly.

Validate Vendor Claims

Configure the edit logic internally and verify with vendors’ claims output.

Business Intelligence

Readily available real-time claims monitoring and reporting system to assist Executive Management with quick decision-making and prioritization.

Comparison Metrics

Compare metrics & trends using different timelines to measure performance and improvement for Financial, Operational, and Quality goals.

Ideation Pipeline

Generate reports that show areas of opportunity, for example, the most billed specialty, the most frequently billed codes, etc.

Interactive Dashboards

Interactive analytic dashboards with drill-down capabilities.

Payment Intelligence & Decision-Making

You’ll have the ability to make timely and effective business decisions based on reporting insights such as current trends/anomalies, resulting in continuous improvement.

Integrated Reporting

Real-time access to all processed claims and standard reports

Standard Reports

Readily available, industry-specific standard reports and reporting templates

Custom Reports

Create your own custom reports and save them for future claims processing without duplication of effort every time claims are run.

Shareable

Share reports with actionable insights with your peers, and also use them for managerial reporting.

Filtering Options

Filter for options such as Lines of Business, state, specialties, or services.

Roadmap

CoverSelf’s platform allows teams to design and deploy custom rules, allowing for complete traceability and audit. It also facilitates self-service, care gap identification, and enables proactive oversight to safeguard revenue and avoid penalties.

Fraud, Waste & Abuse Analytics

Detect FWA patterns using industry-standard trends and AI/ML for promoting payment accuracy and efficiency.

Audit Algorithms for medical review

Detect claims that have certain unusual patterns for pre-pay or post-pay audits.

Case Management

Assign, track and process all cases of Payment Integrity in one place and enable collaboration across different teams for fast and efficient resolution.

Episode Grouper

Services are grouped based on utilization for specific diseases for benchmarking across different use cases.

Value-Based and Alternative Care Models

Coverself’s VBC Solution enables Payers and Providers to enhance quality performance across patient and member populations for MIPS, HEDIS, and CMS Star Rating programs through its comprehensive measurement library, pre-built dashboards, and a highly configurable rules engine that can compute complex quality measures.

Knowledge Bank & Encoders

High-quality Knowledge Bank and real-time code hunting application support medical coding and billing requirements.

Claims Editor

Self-Directed Domain-Specific Platform

Designed with all the use cases that are essential for creating, managing, and updating the reimbursement payment policies for the Payment integrity domain.

Built-In Industry code sets and policies

Pre-configured industry code sets and rules that are continuously auto-updated.

DIY or Delegate - the choice is yours to make

Configure policies and write your proprietary business rules using our exceptionally easy-to-

Policy Management

Ideate, create, customize, manage, test & publish policies & scenarios within hours without losing

Extendable to all healthcare LOBs

Pre-pay and post-pay capabilities across all healthcare LOBs.

Robust Rules Library

Modular
Package

Complete flexibility to choose any library package or specific rules based on

All Healthcare
Lines Of Business

Library for each line of business such as Medicare, Medicaid, commercial,

Complex Logic &
All Claim Types

Complex logic such as MPR, Bilateral, and Duplicate Logic across

Payer-Specific
Library

Configure or customize health plan-specific rules & homegrown code.

Ideation Platform

New Savings Opportunities

A platform that empowers domain experts to ideate, create, validate, test, and implement rules and new concepts on the fly without high technical dependency. Powered by our domain-specific

“What If” Scenario

You’ll have the ability to identify & create new savings opportunities and then test their impact

Impact Analysis

Measure Rules Edits vs Savings at various thresholds prior to finalizing and publishing a

Speed to Release

Innovate and customize new product lines based on varied customer needs with the power to

Data Mining and Analysis

Create scenarios to identify any anomalies without the need for technical teams. Pull claim fields to find patterns with SME’s innate knowledge.

Playground for SMEs

SMEs are equipped with the power to play and try out different concepts.

Query

Query across different claim data fields and in combination, quickly.

Validate Vendor Claims

Configure the edit logic internally and verify with vendors’ claims output.

Payment Intelligence

Business Intelligence

Readily available real-time claims monitoring and reporting system to assist Executive Management with quick decision-making and prioritization.

Comparison Metrics

Compare metrics & trends using different timelines to measure performance and

Ideation Pipeline

Generate reports that show areas of opportunity, for example, the most billed

Interactive Dashboards

Interactive analytic dashboards with drill-down capabilities.

Payment Intelligence & Decision-Making

You’ll have the ability to make timely and effective business decisions based on reporting

Integrated Reporting

Real-time access to all processed claims and standard reports

Standard Reports

Readily available, industry-specific standard reports and reporting templates

Custom Reports

Create your own custom reports and save them for future claims processing

Shareable

Share reports with actionable insights with your peers, and

Filtering Options

Filter for options such as Lines of Business, state, specialties, or services.

Hyper-Customization

An open & extremely customizable platform adapting to the ever-evolving complex world of payment systems, payer needs and compliance policies.

Tailor-Made

Ability to customize from industry-standard libraries, health plan-specific rules, and payer-specific tailored logic.

Custom-Made Payer Features

Ability to add payer-specific custom attributes to the Platform.

Versioning

Create and run multi-version rules based on industry updates or customizations. Versioning capability to run rules based on the different effective dates

Exemption Management

Customize and create bypasses at different levels such as Provider Specialty, Groups, Modifiers, etc.

Payer-Specific Data

Create or customize rules incorporating payer-specific data sources.

Key Differentiators

100% In-house Technology

Completely in-house technology built from ground up, gives the flexibility to customize the platform based on dynamic needs of the payers and industry.

First ever entirely Self-manageable, Purpose-Built Platform

Easy-to-use, create or customize any healthcare policies without dependency or losing IP protection

Open and Transparent Platform

Open access to the Policy Library and Policy Management System.

Access to Rule References

Gain access to Provider-friendly rule references and rationale along with our Policy Management System that will help your customer service team to resolve queries faster and reduce provider abrasion proactively.

Payer-Specific
Claims Auto-Correction

Claims are corrected and processed automatically – no additional work for the payer or provider - which in turn helps constantly reduce waste across Payment Integrity functions and workflows.

Flexible and Predictable Business Model

Easy-to-use, create or customize any healthcare policies without dependency or losing IP protection.

Speed To Market

Cloud-native and scalable platform that fosters innovation and faster release cycles.

Modular library

Choose any policy or rule to fit your needs.

One-Stop Solution

Single integrated platform that enables collaboration without switching between different platforms.

Self-Directed Domain-Specific Platform

Robust Rules Library

Modular Package‍

All Healthcare Lines Of Business

Complex Logic & All Claim Types

Payer-Specific Library‍

New Savings Opportunities

Data Mining and Analysis

Playground for SMEs

Query

Validate Vendor Claims

Business Intelligence

Integrated Reporting

Standard Reports

Custom Reports

Shareable

Filtering Options

Roadmap

Claims Editor

Self-Directed Domain-Specific Platform

Robust Rules Library

Modular Package

All Healthcare Lines Of Business

Complex Logic & All Claim Types

Payer-Specific Library

Ideation Platform

New Savings Opportunities

Data Mining and Analysis

Playground for SMEs

Query

Validate Vendor Claims

Payment Intelligence

Business Intelligence

Integrated Reporting

Standard Reports

Custom Reports

Shareable

Filtering Options

Self-Directed Domain-Specific Platform

Robust Rules Library

Modular Package

Modular Package

Modular Package

Modular Package

Hyper-Customization

Key Differentiators

100% In-house Technology

First ever entirely Self-manageable, Purpose-Built Platform

Open and Transparent Platform

Access to Rule References

Payer-Specific Claims Auto-Correction

Flexible and Predictable Business Model

Speed To Market

Modular library

One-Stop Solution

NHCAA Annual Training Conference

Modular Package
‍

Payer-Specific Library
‍

Modular
Package

All Healthcare
Lines Of Business

Complex Logic &
All Claim Types

Payer-Specific
Library

Payer-Specific
Claims Auto-Correction