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CMS Program Audit Universe Management Solution CMS Program Audit Universe Management Solution

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          Universe Scrubber

          Traditionally, health plans commit resources for months while setting up all the data to comply with regulatory audits. Inovaare optimized the implementation process so that health plans can start using this powerful CMS universe validation and report generation tool within a week.

          Inovaare’s Universe Scrubber scrubs Centers for Medicare and Medicaid (CMS) Program Audit universe reports and flags all crucial errors. This, alone, optimizes operational efficiency.

          However, Universe Scrubber also analyzes universe tables for authorizations, claims, appeals and grievances CMS universes—such as Part C Organization Determinations, Appeals and Grievances (ODAG), Part D Coverage Determinations, Appeals and Grievances (CDAG) and Medicare-Medicaid Plan Service Authorization Requests, Appeals and Grievances (SARAG)—and other regulatory universes in real time. Payers can also monitor the health of their plans, on demand, by running Universe Scrubber monthly, weekly or even daily.

          With all CMS universe tables embedded, Universe Scrubber provides access to real-time data so health plans can validate their CMS Program Audit universe tables in three simple steps:

          1. Upload universe file
          2. Scrub to validate
          3. Review and publish

          Universe Scrubber empowers health plans to:

          • Identify turnaround times and outlier issues, as well as errors in universe formatting, data and business logic
          • Proactively audit and monitor first-tier, downstream and related (FDR) delegated entities
          • Reduce effort in preparing universe submissions
          • Increase productivity by improving collaboration within the organization
          • Benefit from preconfigured business rules based on up-to-date regulatory mandates
          • Customize configuration based on company-specific business rules
          • Make better decisions based on automated analytics that leverages real-time data to generate intuitive dashboards and KPI reports

          Inquire how

          Universe Generator

          Health plans can reduce the risk of penalties and lower CMS Star Ratings by increasing report turnaround times. Universe Generator will do just that by enabling users to create properly formatted universes with the click of a button.

          Universe Generator gathers data for requested date ranges to create clean universes for submission, even from multiple submitters providing the same universe table. It then compiles scrubbed universes into a single table for continuously compliant CMS report submission.

          Universe Generator can be prebuilt with each report in the approved format for layout and data type and, when used regularly, this tool empowers payers to continuously monitor the health of their plans.

          Additional benefits allow compliance teams to:

          • Generate universes with reduced dependency on IT teams
          • Meet their own data requirements or query requests
          • Maintain audit readiness at all times

          Inquire how

          FDR Universe Manager

          Work collaboratively with your delegated entities through our FDR Portal, which accesses and consolidates CMS Program Audit universes submitted by delegates. This efficiency ensures health plans can produce more accurate results with fewer resources to manage, monitor and audit FDRs.

          FDR Universe Manager allows a health plan’s delegated entities to scrub and submit universes for review and potential remediation through a secure portal. This reduces the back-and-forth communication typically required for delegate universe submissions.

          The automated workflow takes care of the manual processes to:

          • Identify outliers
          • Expose potential risks
          • Achieve faster turnaround times
          • Reduce effort and costs
          • Track FDR submissions and issues

          Inquire how

          Provider Dispute Resolution

          Most states require health plans to pay healthcare providers accurately and timely for their services. In parallel, payers must maintain a fast, fair and cost-effective system for processing and resolving provider claims. Health plans must also submit annual reports regarding the number, type and provider claim payment-dispute summaries. They are required to describe the resolutions including terms and timeliness and explain how they are addressing trends or patterns in disputes.

          With Provider Dispute Resolution (PDR), health plans can:

          • Monitor and manage PDR processes efficiently
          • Track provider disputes in real time
          • Ensure consistent compliance

          Inquire how

          QIO Appeals

          The Quality Improvement Organization (QIO) Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human (HHS) Services’ National Quality Strategy for providing better care and outcomes at lower costs. CMS relies on QIOs to improve the quality of healthcare for all Medicare beneficiaries.

          Inovaare’s QIO Appeals solution helps:

          • Ensure QIOs are tracked at each step, from intake through closure
          • Guarantee each decision rendered is executed efficiently
          • Support timeliness

          Inquire how

          Issue Management

          Architected by CMS regulatory compliance experts, Inovaare ensures health plans can effectively track and manage issues that have been identified as a risk or potential non-compliance. This includes automating corresponding follow-up actions and activities. Inovaare's Incident Management module empowers regulatory compliance management teams to drive continuous improvement activities across the entire enterprise. Now, payers can analyze trends, draw insights across multiple departments, implement and track corrective actions and then accurately measure real-time results.

          Inovaare ensures health plans can:

          • Facilitate and centralize any incident that could potentially be a risk to the organization
          • Determine if it is a risk or not (pre-screen or triage the risk/incident)
          • Track resolution from start to finish
          • Incident tracking & reporting (FWA, SIU, etc.)

          Inquire how

          Corrective Action Plan (CAP)

          Inovaare’s Corrective Action Plan module automates CAP monitoring, assigns issues for resolution and records results of root-cause analysis. Now, health plans can:

          • Automate or simplify the approval process
          • Implement tasking and reporting
          • Expedite resolution of issues identified within the organization and non-compliance issues regarding customer complaints
          • Monitor CAP results to reduce errors, perform trend analysis and identify the root-causes

          Inquire how

          Regulatory Library

          Inovaare’s cloud-based Regulatory Library module ensures an efficient process is in place to manage memos and ensure health-plan compliance is not consistently at risk. It equips health plans to streamline review processes and coordinate communication across all departments as well as update and monitor required due dates.

          In addition to the ability to auto-load HPMS memos, efficiently monitor State Notices and improve department adherence to memorandums and quickly identify any corrective actions, health plans benefit from:

          • Regulations Upload: Centralized location to upload & review regulations
          • Task Management: Provides ability to create, manage & track tasks by department, state and line of business (LOB)
          • Analytics Dashboard & Reports: Available for regulations and tasks by state, LOB, department, due date, count, risk level, status, owners, etc.
          • Citation & Hyperlinks Creation: Available for uploaded regulations
          • Keyword Search: Search regulations by ID, type, date, etc.
          • Compliance Acknowledgement: Record of effective compliance communication via the ability to attach proof of Compliance & Compliance Manager to approve & acknowledge the compliance
          • Risk Management: Potential risks can be identified, tracked & mitigated by effectively communicating with Operational & Compliance stakeholders
          • Automated Reminders and Notifications: Internal/external stakeholders and PGA (Policy & Government Affair) can receive timely notifications and reminders
          • Communication: Collaborate with regulatory owners, functional owners, compliance owners & other organization stakeholders

          Inquire how

          Contract & Policy Tracking

          Enable proactive management of all contracts including those with vendors, service providers, customers and business partners. Facilitate collaboration using fully customizable workflow processes for review and approval.


          • Track communications between you and your regulator
          • Simplify the approval process
          • Monitor key deliverable dates


          • Manage contract life cycle
          • Track and monitor compliance as well as regulatory quality management
          • Access to a central compliance system that connects different departments and systems

          Inquire how

          Policies & Procedures

          Policies and Procedures is a comprehensive cloud-based platform built for the healthcare industry that allows organizations to publish, assess and manage their policies and procedures. Health plans can create and/or review drafted policies, signoff and automate the full life-cycle management process of policies and procedures, including customizable workflows for review and approval.

          Inovaare's cloud-based Contract and Policy Tracking module allows regulatory compliance management teams to:

          • Collaborate across the entire health plan as well as store and manage all regulatory contracts and policies
          • Automate the contract and policy life cycle to increase productivity
          • Find documents and manage expiration dates—including Optical Character Recognition (OCR)

          Inquire how

          Risk Management

          Inovaare’s Risk Management solution surveys and gathers evidence to determine risk. The module provides a single interface that users can access to create and edit attestations as well as change scoring parameters. Health plans can: complement existing risk-management policies and procedures with templates, metrics and workflows; minimize and manage corporate risks to lower the risk levels and reduce the organization’s direct costs; and maintain end-to-end audit trails.

          Inovaare’s cloud-based Risk Management module empowers health plans to:

          • Exert stronger control over a wide array of internal and external risks including market, strategic, financial, operational, IT, legal, brand issues
          • Minimize and manage reputation-related issues
          • Integrate and monitor corrective action plans

          Inquire how

          Internal Audit

          Demand for continuous risk management and control systems is on the rise, so organizations are adopting automation to support their audit teams. Inovaare’s Internal Audit module helps health plans manage end-to-end audit processes efficiently by delivering a systematic, risk-based audit system that streamlines workflows and provides real-time reporting. This allows health plans to attain a holistic view of the organization’s governance, risk and compliance status.

          This cloud-based audit solution empowers health plans to:

          • Drive an agile internal audit program aligned with organizational goals
          • Prepare for multi-dimensional risks, while preserving the trust of every stakeholder
          • Reduce the time spent on sifting through mountains of data to mine insights
          • Increase productivity and accelerate business performance
          • Manage a wide range of audit activities, data and processes in a unified manner

          Key Features

          • Facilitates a structured, risk-based approach to internal and external audits across the enterprise.
          • Integrates audit life cycles, including audit planning and scheduling, checklist preparation, field data entry, audit report generation, corrective actions and risk mitigation
          • Provides a comprehensive picture of the audit activities status
          • Stores and organizes audit questionnaires and worksheets regarding findings, non-compliance, observations, documentation and all relevant corrective actions


          • Improve business performance by aligning audits with strategic objectives and risks
          • Optimize audit productivity by prioritizing resource allocation based on the areas of highest risk impact
          • Increase collaboration by standardizing the audit execution methodology across teams
          • Simplify control-testing processes using a streamlined approach, which frees up time for value-added activities

          Inquire how

          Provider Dispute Resolution


          Advanced Solution for Resolving Provider Disputes Efficiently

          Provider Disputes leverages Intelligent Automation to accelerate the resolution process for provider disputes and complaints. Provider Disputes is guided by a compliance rules engine which helps to ensure you stay compliant even when it is not top of mind. This robust solution offers all the necessary tools for Provider Dispute Leadership and PD Specialists to hyper-personalize each case until successful completion.

          Solution Overview

          • Provider Dispute Solution acts as a “Compliance Partner” proactively updated with the current regulations
          • Fully integrated solution bridging the gap between initial claims and provider disputes
          • Strong return on talent through intuitive workflows and built-in rules and logic to optimize efficiency
          • Auto-management of case timeliness through case prioritization and alerts/notifications
          • Provides leadership with insights on unhappy providers to get them back on the “Happy Path”

          Key Features

          • One-Click Generation for all Regulatory Reporting
          • Workforce Management tools to optimize resources
          • Letter Management Module efficiently manages provider correspondence
          • Streamlined workflows for increased team productivity
          • Global Communication tool allowing for effective communications to internal partners and external vendors

          Inquire how

          Business-Process-as-a-Service (BPaaS)


          Health plans trust us to take their Customer Service, Appeals & Grievances and Provider Dispute Departments to a world-class level by incorporating our Industry-Leading Technology, implementing Best Practices, and adding our Expert Professionals to your team.

          A Reliable Non-Delegated Arrangement for Hassle-Free Operations Management

          This BPaaS program includes the full suite of our solutions as well as industry experts who can fill all key operational Customer Service, Appeals and Grievances, and Provider Dispute roles. It also includes automated compliance solutions, which helps to elevate your A&G Department’s compliance adherence and operational efficiency.

          With proactive regulatory updates, built-in rules and logic, and workforce management tools, it’s a holistic solution for healthcare organizations aiming to improve performance, achieve return on talent, and fast track the level of other high-performing health plans/organizations.

          Best of all, our BPaaS quickly takes operational departments to the next level while also driving down the total cost of ownership.

          Inquire how

          Member Services CRM: Member Experience & Compliance Designed into the Core


          Health plan leaders face complex challenges in member interactions across multiple channels. Ensuring seamless centralization and maintaining regulatory compliance in these interactions is crucial. These challenges include coordinating multiple departments for issue resolution and providing real-time access to customer histories, as well as the need to schedule future activities efficiently.

          Inovaare offers a Member Services CRM solution tailored to the unique operational and compliance requirements of healthcare payers. Our platform streamlines the coordination process, enhances visibility across customer interactions, facilitates regulatory compliant reporting with ease, and supports health plans in delivering effective and compliant member services. The Member Services CRM—powered by real-time omnichannel and end-to-end workflow automation—delivers improved member experiences through more efficient processes.

          Solution Overview

          • 360 View of member experiences
          • Member Services CRM Solution protects against case type misclassifications
          • Optimized productivity with 2-Step case closures
          • Smart Guided Interactions driving next best steps for both quicker and impactful resolutions
          • Alleviates workforce pressures through smart augmented automation

          Key Features

          • Self-service one-click generation for all Operational & Universe Reporting
          • Workforce Management tools to optimize resources
          • Knowledge Management Module efficiently improving entire team productivity
          • Centralized incoming case document queue for web, fax, and email channels
          • Global Communication tool allowing for effective communications to internal partners and external vendors

          Request Demo

          Internal Monitoring

          Sustaining compliance is a challenge, since CMS and state regulatory requirements change frequently. However, by implementing internal checks and reviews, health plans can gain better visibility of their quality control and compliance processes.

          Continuous monitoring of your compliance program not only helps improve operational health, but it demonstrates to the CMS that your health plan takes compliance seriously. Inovaare’s Internal Monitoring solution assists health plan to:

          • Streamline review processes to ensure necessary policies and procedures help minimize compliance risks
          • Support collaboration across teams
          • Optimize workflows to improve turnaround times
          • Lower operating costs while improving remediation processes

          Inquire how

          External Audit

          External auditors are essential to ensure health plans meet their governance, risk management and compliance (GRC) requirements. Inovaare’s External Audit solution enhances the exchange process through its compliance-driven platform.

          Embedded with all applicable federal and state regulations — including Medicare Part C, Medicare Part D and Medicaid — this cloud-based module helps heath plans to:

          • Support transparency and increase risk awareness to facilitate better decision making
          • Align audits to strategic objectives and risks
          • Optimize audit productivity by prioritizing resource allocation based on the areas of highest risk impact
          • Standardize the audit execution methodology across teams

          Inquire how

          Delegation Oversight

          Inovaare’s Delegation Oversight module enables health plans to manage first-tier, downstream and related (FDR) delegated entity compliance. Now, Delegation Oversight departments can perform systematic reviews of FDR operations—to ensure they are in line with business requirements—while empowering plan sponsors and MCOs to manage and track all audits and monitoring of delegated entities. The module also provides a secure portal for communication where delegated entities can scrub their universe files before submitting them to the health plan.


          • FDR Audit
          • FDR Monitoring
          • FDR Scheduling
          • FDR CAP
          • FDR Tracking & Scoring

          Inquire how

          Member Services

          Experience the difference. Inovaare’s CRMؙ—Member Services is the only solution that shares the same platform as Appeals & Grievances and CRM—Provider Services. This singular platform delivers better member experiences powered by end-to-end workflow automation. Inovaare’s CRM—Member Services was architected by leaders who oversaw Member Services departments and, as a result, we understand your requirements for Medicare, Medicaid and Commercial plans. Our industry-leading solution helps health plan to:

          • Eliminate misclassified cases
          • Increase staff productivity with 2-click case closures
          • Empower the entire Member Services department with embedded Knowledge Management

          Inquire how

          Provider Services

          Experience the difference. Inovaare’s CRM—Provider Services is the only solution that shares the same platform as CRM—Appeals & Grievances and CRM—Member Services. This singular platform delivers better provider experiences powered by end-to-end workflow automation. Inovaare’s CRM—Provider Services was architected by leaders who oversaw Provider Services department and, as a result, we understand your requirements for Medicare, Medicaid and Commercial plans. Our industry-leading solution helps health plans to:

          • Obtain a 360⁰ view of all provider issues
          • Increase staff productivity with 2-click case closures
          • Empower the entire Member Services department with embedded Knowledge Management

          Inquire how

          Workflow Automation

          Streamline your operations with Inovaare's Workflow Automation, designed for efficient process management and enhanced productivity.

          • Low-code and No-code App Builder: Simplify app development with our intuitive low-code and no-code platforms. These tools empower your teams to build custom applications quickly without deep technical knowledge, accelerating your digital transformation.
          • Intelligent Task Management: Optimize workflow efficiency with AI-enabled task management. Our system prioritizes tasks, predicts bottlenecks, and automates routine processes, freeing your team to focus on high-value activities.

          Inquire how

          Rules Repository

          Ensure data integrity with Inovaare's Data Platform, utilizing sophisticated rule-based controls for impeccable data quality.

          • Scrubber: Ensure the integrity of your data with our advanced scrubbing tools. They automatically cleanse, verify, and validate your datasets based on built-in rules, providing a solid foundation for accurate analytics.
            • Structured Data Scrubber: This tool specifically targets structured datasets, enforcing quality and consistency across your data assets.
            • Unstructured Data Scrubber: Extract value from unstructured data. Our scrubber intelligently interprets text, images, and more, converting them into actionable insights.
          • Data Mart: Create a focused repository of data that is specific to a particular area or need, facilitating quick access to relevant information for decision making.
          • Data Analytics: Gain deeper insights with our comprehensive data analytics suite. Explore trends, forecast outcomes, and understand your data with advanced analytical models.
          • Ad hoc Reporting Platform: Address immediate data queries with our Ad hoc reporting tool. Generate reports on-the-fly to support dynamic decision-making processes.

          Inquire how

          Analytics & Reporting

          The Analytics & Reporting component is engineered to empower healthcare payers with deep insights and comprehensive reporting capabilities. The data platform sees data as a strategic asset and intelligently transforms complex data into actionable intelligence, helping organizations drive operational excellence, be on-point with compliance, and enhance strategic decision making.

          • Advanced Data Analytics: Leverage the power of real-time analytics to unlock valuable insights from your data, enabling a proactive approach to driving operational efficiency.
          • Flexible Reporting Tools: Craft customized reports with ease, tailored to the unique needs of your organization, for a deeper understanding of critical metrics and outcomes.
          • Performance Dashboards: Monitor your organization’s performance through intuitive dashboards, providing a snapshot of key metrics at a glance.
          • Regulatory Reporting Made Simple: Automate your compliance reporting with tools designed to build reports for healthcare regulations effortlessly.
          • Trend Analysis: Identify and analyze trends within your data to forecast future needs and opportunities for improvement.
          • Performance Monitoring: Track KPIs to gauge success and identify areas for enhancement.

          Inquire how

            CMS Program Audit Universe Management

            Submit CMS Program Audit ready Universes with the touch of a button.

            Universes Not Just For CMS Audit Anymore

            Leverage the power of the data within

            • Universe Scrubber

              Scrub and validate CMS Universe tables in 3 simple steps

            • Universe Generator

              Generate properly formatted CMS universe tables with the touch of a button

            • FDR Universe Manager

              Enable first-tier, downstream and related entities to access a Delegated Entity Oversight tool to self-scrub, validate and submit properly formatted universes through a secure portal

            Generate compliant CMS Program Audit universes

            Reduce time, effort and cost of Program Audit preparation

            Minimize need for outside consultants and part-time hires

            Run mock audits on demand and reduce overall costs

            Demonstrate ability to monitor key operational elements

            Inovaare knows the magic of CMS Program Audit universe tables

            Practice, Practice, Practice. CMS stresses that practice is critical to produce accurate universes and achieve a successful CMS Program Audit. But what about ongoing monitoring, mock audits and TMP audits? What about leveraging your different departments to ensue quality data validation and produce better overall compliance?

            Regardless of  your Medicare Advantage and/or MMP plan size — whether you have 80 or 8,000,000 members — Inovaare delivers scalable solutions to fit your regulatory compliance requirements, starting with our Universe Management System.

            Experience the ultimate solution that provides continuous oversight of your operational areas and FDRs.  Whether you are preparing for a CMS Program Audit, running a Scheduled Mock Audit or conducting routine monitoring, Universe Management System has you covered. Outliers are highlighted with detailed information based on the thousands of rules incorporated , which allows you to investigate issues rather than spending time searching for them.

            Inovaare’s Universe Management System is an end-to-end solution comprised of three standalone modules that can be seamlessly integrated to ensure health plans submit CMS-compliant reports with the touch of a button.


            Universe Scrubber

            Within days of purchase, Universe Scrubber automatically scrubs reports for authorizations, claims, and appeals and grievances—on demand—to validate all CMS universes (ODAG, CDAG, SARAG, CPE, FA, SNP-MOC, CCQIPE) in real time. Health plans can now:

            Universe Generator

            This cloud-based CMS compliance software module can be pre-built for single-click report generation. Each report created conforms to the approved layout and data-type format accepted by regulatory authorities. Compliance teams can:
            Delegated Entity Collaboration Portal

            FDR Universe Manager

            Collaborate with first-tier, downstream and related (FDR) entities through our state-of-the-art FDR portal. Our FDR Universe Manager delivers unparalleled oversight and empowers health plans to:



            Fulfill data needs with little dependency on IT

            Continuous Monitoring

            Turn universes into powerful tools to monitor compliance

            Delegated Entity Management

            Empower Delegated Entities to submit compliant and timely universes


            Merge different workflows into a unified process for universe management

            Risk Management

            Track findings, recommendations and corrective actions in real time

            Ad hoc Reports

            Own your data to generate real-time ad hoc reports and analytics

            Audit Reports

            Generate consolidated reports in a matter of minutes

            360-degree Oversight

            Gain 360-degree oversight of audit and monitoring processes in real time


            Take a lighthearted tour within a fictitious health plan as they fret over a CMS Program Audit . . . until Inovaare’s industry-leading solution saves the day.



            Ensure your health plan submits accurate, properly formatted CMS regulatory reports with the touch of a button.

            CMS AUDIT BLOG

            Are you ready for 2022? Forewarned is Forearmed: Prepare for 2021 CMS Audit Protocol Changes will help.


            Explore how to proactively manage universes in this webinar: Compliance Favors Only the Prepared Plan.


            Discover how Universe Scrubber can revolutionize the audit preparation processes.


            Learn how a Fortune 500 health plan serving Medicare and Medicare-Medicaid (MMP) members achieved an 80% reduction in CMS Program Audit data-submission efforts.

            CASE STUDY