Quality and Performance solutions

Analyze, communicate, and improve your clinical and financial performance


As value-based reimbursement becomes the standard, Cotiviti’s Quality and Performance solutions allow health plans to move from simply reporting quality measures to driving the purchase, delivery, and utilization of higher value healthcare. Our solutions enable health plans to collaborate more effectively with their provider networks, with members, and with other functional teams within the plan itself. The result? Plans can successfully manage members’ clinical and financial risks, make the most of limited internal resources, and stay compliant with industry requirements and regulations.





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Take your quality improvement program to the next level

Quality improvement is complex, evolving, and increasingly tied to financial profitability. Cotiviti can help you turn quality measurement and reporting into the rock-solid foundation you need to support such mission-critical initiatives as population health, quality improvement, compliance, network management and contracting, and value-based reimbursement. We blend our NCQA-certified measure logic and easy-to-use reporting software with high-volume, expert retrieval and abstraction services for overall process excellence, driving the best results with the least amount of your effort at every stage.

Powerful, award-winning software

With a unified view across measures, Quality Intelligence drives a level of efficiency that enables proactive year-round measurement and reporting, allowing health plans to continuously refine their quality improvement programs and achieve better results.

Quality Intelligence won the 2017 Best in KLAS award for payer quality analytics and reporting solutions. KLAS Research used its well-established methodologies and exhaustive customer research to evaluate vendor and solution performance across multiple categories. Customers noted, in particular, that Cotiviti leads the competition in terms of software performance and ease of use.

Accurate, resource-efficient services

The thorough documentation of compliant care leads to improved quality scores. Cotiviti has extensive, proven experience performing medical record retrieval and abstraction services for a wide range of purposes. The volumes that we process have provided us with vast historical provider-related details (stored in our unique master record locator) about how best to obtain records without disrupting the physician office. In addition, our abstractors undergo rigorous training to achieve the highest number of compliant components possible within any reporting timeframe.

Customer support excellence

Quality measurement and reporting is tough, and the last thing you need is a vendor that makes it tougher. Cotiviti has a well-known reputation for flexibility and dedication to client satisfaction. We take your trust in us as a partner seriously and provide thoroughly trained and experienced resources; timely responses and product updates; and accurate, rapid, secure data management processes at all times.


The Quality Intelligence software forms the solid foundation of an effective quality improvement program. From there, you can add solutions to gain even more value.

quality_performance_solution_quality_intelligenceQuality Intelligence

Measure and report HEDIS and HEDIS-related metrics your way

Quality Intelligence, our fully NCQA-certified quality measure logic and reporting software, sets the standard for efficiency, ease-of-use, and customer satisfaction. Health plans can track, monitor, and improve quality compliance; develop and measure proprietary quality metrics; facilitate HEDIS, Star Ratings, and other quality measure submissions; and implement a year-round measurement and reporting program that significantly improves health plan rankings. Maybe that’s why 68 percent of health plan members for whom HEDIS scores are reported run through our software. 

Clients can choose from two deployment options:

  • Full service, in which designated Cotiviti data operations personnel support your runs throughout the year
  • Self service, where you have the flexibility to set your own processing schedule and number of data runs and otherwise own the entire process

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>250 quality measures—and growing

Quality Intelligence is a powerful resource that you can use to keep a vigilant eye on complex, wide-ranging, and evolving healthcare quality metrics. Supported measure sets include:

  • AHCA  (Florida Medicaid)
  • California P4P 
  • California Medi-Cal MCAS
  • CMS Adult and Children Core Sets
  • CMS Star Ratings Part D and Survey
  • Covered California
  • Custom HEDIS-like Rolling Measures 
  • Georgia Medicaid 
  • Hawaii Medicaid Quest Integration 
  • HEDIS 
  • Illinois Medicare/Medicaid
  • Kentucky Medicaid
  • Louisiana Medicaid 
  • Maryland 
  • Mass. Group Insurance Commission
  • MN Community Measurement
  • New Jersey 
  • New York QARR 
  • Pennsylvania Medicaid CHIP and PAPM
  • Pharmacy Quality Alliance (PQA)
  • Vermont ACO
  • West Virginia Medicaid


quality_performance_solution_star_navigatorStar Navigator

Benefit from a deeper level of support to optimize Star Ratings


Star Navigator is a quality improvement solution that helps Medicare Advantage plans determine the most direct path to higher Star Ratings, then track and communicate their progress toward goals. With Star Navigator, health plans gain the insights necessary to efficiently close care gaps, enlisting providers as partners in quality improvement while providing a better member experience. Star Navigator eases the process of tracking annual changes to the program from the Centers for Medicare & Medicaid Services (CMS) and requires minimal IT support, providing a turnkey solution for Star Ratings optimization.

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quality_performance_solution_medical_record_retrievalMedical Record Retrieval

Fulfill even high-volume record requests with minimal disruption to providers and their office staff


Cotiviti’s Medical Record Retrieval services streamline medical record retrieval, aggregation, indexing, and storage. With Cotiviti, plans can easily achieve or exceed their retrieval targets because we use provider weighting algorithms to avoid unnecessary effort, eliminate medical record image transfer downtime, and offer full transparency into retrieval status at request, project, and provider levels. This is why we’ve exceeded the market standard in medical record retrieval for the past two years, and have achieved a greater than 90 percent retrieval rate on average over the last three.

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quality_performance_solution_medical_record_abstractionMedical Record Abstraction 

Achieve the highest number of compliant components possible within any reporting timeframe


Cotiviti experts abstract medical record information to validate that recommended care has been provided, supporting health plan quality measurement submissions.

Two qualities set Cotiviti apart in the delivery of abstraction services and account for our greater than 97 percent accuracy rates since 2015. First, focus, rigorous training, and continuous quality assurance ensure consistent performance, and our experts are just a phone call away for any questions. Second, we are incredibly flexible: We can support client-specific data formats including abstraction and over-read, MRRV only, direct EMR abstraction, and off-season projects—and we can easily scale to meet your needs, no matter the volume.

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Cotiviti performance analytics solutions

Tame your data and optimize your clinical and financial performance with one partner

Payers and every other healthcare stakeholder need answers to highly complex questions about healthcare costs, quality, utilization, and value. Use of advanced data analytics leads to the efficient, accurate discovery of critical business performance insights.

Cotiviti’s performance analytics solutions simplify the aggregation and organization of healthcare data to uncover member-, population-, and provider-level opportunities to mitigate clinical and financial risk.


Deep and broad analytic capabilities

Our solutions help payers, providers, self-insured employers, insurance brokers, third-party administrators, government agencies, and anyone else interested in a deep understanding of healthcare risk and utilization.

  • Population risk identification and stratification: organize and prioritize any population with speed, accuracy, and superior predictive power using DxCG Intelligence, the industry’s gold standard in risk adjustment and predictive modeling for decades
  • Performance trending: find opportunities in the complex interplay of healthcare cost, quality, and utilization data
  • Individual-level clinical insights: get the drilldown insights into each healthcare consumer that drive the most effective interventions
  • Provider performance assessment and network management: identify key trends at the provider level that drive more effective collaboration with your provider network in quality improvement, network management, and the pursuit of value-based care
  • Ad hoc data integration and reporting: take a deep dive into data discovery and visualization to deliver enhanced reporting


Data management excellence

Our track record of success in managing very large claim sets and other clinical data—we process more than 75 billion claims files per year for an extensive array of purposes—allows risk-bearing entities to create a true longitudinal record across many settings of care and gain insights to fuel both current and future-state strategies.


Industry-leading analytics

DxCG risk adjustment and predictive models were developed in partnership with CMS and served as the foundation for its Hierarchical Condition Category (HCC) models. DxCG has proven its continued, expanded utility in evolving payment programs (e.g., Medicare Advantage, Health Insurance Marketplace).

DxCG has an extensive worldwide customer base that includes nearly 500 organizations. It is the preferred choice of the nation’s leading health plans, third-party administrators, providers, accountable care organizations, state Medicaid agencies, Health Insurance Exchanges, self-insured employers, and benefit brokers/consultants, and it is used extensively by leading academic institutions to inform research.

Cotiviti’s Network Intelligence solution helps payers and providers collaborate to create and manage value-based healthcare delivery and payment. We enable an innovative new approach to medical economics that helps clients recognize and reward high-value care while reducing  low-value care and other unnecessary payments from the healthcare system. We take payers through the high-value journey, helping them socialize and educate their providers about value. Then, we put data into action to incentivize change.


A partner you can trust

For decades, Cotiviti has been singularly focused on data management and analytics, which allows us to truly lay claim to broad and deep risk management expertise. We listen and learn, which has earned us the reputation for creating long, collaborative, and productive partnerships with our clients in which their success is always our top priority.

DxCG models and their proven science form the solid foundation of an effective performance improvement program. From there, you can add solutions to gain even more value.

quality_performance_solution_medical_intelligenceMedical Intelligence

Gain insights into every facet of healthcare utilization

Medical Intelligence combines Cotiviti’s industry-leading DxCG models, evidence-based clinical quality rules, healthcare utilization metrics, and claims-based HEDIS measures to enable payers to manage risk and target opportunities for improving healthcare results. Users can easily stratify and segment populations (by risk, costs, utilization, predicted future cost, or location), access member-level detail (e.g., conditions, comorbidities, clinical events, gaps in care, prescription compliance), and evaluate efficiency and performance by program, provider, and more.

For population health management, Medical Intelligence helps:

  • Identify and stratify member risk and match members to the appropriate interventions
  • Pinpoint those at risk for hospitalization or emergency room (ER) use in the near future
  • Optimize the results and operational efficiency of outreach and engagement initiatives

For clinical program design and evaluation, Medical Intelligence helps:

  • Analyze population and member-level conditions, gaps in care, quality, and compliance metrics
  • Monitor and measure the progress of disease management and wellness programs and vendors
  • Identify new intervention programs needed to address conditions driving cost and utilization 

For network management, Medical Intelligence helps:

  • Assess the impact of out-of-network utilization
  • Inform pay-for-performance, accountable care, and other alternative quality contracts

For medical cost management, Medical Intelligence helps:

  • Analyze utilization patterns to identify waste and drive appropriate use of medical resources
  • Identify conditions and members driving costs and utilization patterns

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Up the value

Clients have the option of adding two components to their Medical Intelligence implementation:

  • Provider Intelligence: three additional analytic modules that deliver provider management tools, in/out-of-network analysis, and home health agency analytics
  • Enterprise Intelligence: enhanced visualization and reporting that enables power users to dive deep into data discovery and visualization, leveraging online analytical processing (OLAP) technology
quality_performance_solution_DxCG_intelligenceDxCG Intelligence

Clearly understand and predict individual and population risk

Part of healthcare’s DNA for 20 years, DxCG Intelligence is the gold standard in risk adjustment and predictive modeling. DxCG Intelligence uses Cotiviti’s proprietary predictive models to turn healthcare data into risk scores for individual patients and identify primary drivers of the risk. Scores correlate with the cost of the underlying illness burden that individuals carry. Aggregating the scores of individuals with key attributes generates group-level predictive results that can be applied to answer questions fundamental to the ability to manage clinical and financial risks.

Nearly 500 organizations use DxCG Intelligence, which provides a common language of risk adjustment for healthcare payers and providers, for employers, for government agencies, and for academic researchers investigating ways to improve healthcare administration and delivery.

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Superior predictive power

Cotiviti has been honored to advance the science of risk scoring by working with the Society of Actuaries (SOA) over the past two decades. SOA’s rigor and effort to resolve potential disparities in the analysis ensure a comprehensive evaluation of commercial risk adjustment and predictive models.

SOA’s latest study was published in 2016. Similar to their previous evaluation in 2007, DxCG models were top performers across the study.

DxCG is the clear industry leader in:

  • Longevity
  • Depth of validation
  • Breadth of scope and models
  • Model utility
quality_performance_solution_network_valueNetwork Intelligence

Obtain the solid foundation you need to shift from volume to value


Cotiviti offers a leading methodology for calculating what is considered to be high-value care, using the Dartmouth Atlas, Choosing Wisely, and other academic research as well as Medicare claims data (Parts A, B, and D). We then benchmark providers across their geographic and specialty peers to identify those who are most likely to succeed in risk-based arrangements. Clients can recognize and reward high-value care while reducing low-value care, allowing them to build and optimize high-performing networks, collaborate with providers, transition from volume to value, and drive down total cost of care.

Our comprehensive engagement model is designed to ensure that payers and providers can successfully partner in providing high-value care within existing payment models while scaling for the future. These valuable analytics form the foundation of an action plan that includes strategy development, roadmap planning, and program delivery for network optimization and development, as well as provider and member behavior change–everything you need to obtain clarity, collaboration, and results.

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Cotiviti’s unique value

A tradition of performance improvement excellence
  • 130+ health plans use our HEDIS reporting solutions representing 125 million members—meaning 68% of the market trusts its quality programs to Cotiviti

  • Nearly 500 organizations of all types rely on DxCG risk models, including 100+ health plans

Collaborative partnerships
  • Not pharma- or payer-owned
  • Long-standing reputation for flexibility and ease in our working relationships
  • Track record of client retention and relationship growth
  • Ongoing commitment to educate our clients on best practices, regulatory issues, and market trends
Breadth of experience
  • Experience meeting the needs of payers, providers, employers, brokers, TPAs, and more
  • Successful data management for hundreds of payers across multiple lines of business and functional areas (e.g., quality reporting, payment accuracy, risk adjustment, network management)
  • Best-in-class implementation and ongoing monthly processing
Singular focus on data analytics
  • Comparative norms, reports, dashboards, analytics, and data mining
  • Comprehensive and physician-intuitive classification systems
  • Unparalleled, multifaceted views into risk drivers to inform data-driven action
  • Critical insights: quality/efficiency of care, medical cost management, provider performance, value-based care delivery
Leadership in innovation
  • Consistent and proven track record of advancing models to build for the future
  • Optimal performance in the face of data, best practice, and payment changes
  • A commitment to modern data science and intelligence models that evolve with our clients’ needs


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