Covenant replaces Epic Tapestry with a managed care administration platform for health systems operating as both providers and payers. As health systems assume insurance risk through Medicare Advantage plans, Medicaid managed care, employer-sponsored ACOs, and commercial health plans, they need the operational infrastructure to manage member enrollment, adjudicate claims, price contracts, and coordinate benefits — the same functions that insurance companies perform, now embedded in the provider organization.
The boundary between provider and payer is dissolving. Large health systems increasingly operate their own Medicare Advantage plans, accept capitated Medicaid contracts, and offer employer-sponsored insurance products. These organizations need claims adjudication, contract management, member enrollment, and benefits administration — functions that were historically the domain of insurance companies. Epic Tapestry provides this infrastructure, but it is one of Epic’s oldest and most complex modules, requiring deep specialization to implement and maintain.
Covenant manages the complete member lifecycle from initial enrollment through coverage changes, dependent additions, and disenrollment. Real-time eligibility verification responds to provider queries in under three seconds, returning coverage status, copay requirements, deductible balances, and prior authorization requirements. Member communications — ID cards, benefit summaries, EOBs, and annual notices — are generated and distributed through the member’s preferred channel.
The claims adjudication engine processes professional (837P), institutional (837I), and dental (837D) claims against the member’s benefit plan, applying contract-specific pricing, coordination of benefits, and adjudication rules. Clean claims are auto-adjudicated without human intervention. Claims requiring review are routed to the appropriate queue with decision support showing the applicable contract terms, benefit limits, and clinical policies.
Managing a provider network requires tracking credentialing status, contract terms, fee schedules, and network adequacy across every specialty and geography. Covenant provides a provider directory with real-time credentialing status, contract expiration alerts, fee schedule modeling for rate negotiations, and network adequacy analysis that identifies gaps in specialty or geographic coverage before they affect member access.
Prior authorization and utilization management are where clinical and administrative functions intersect. Covenant provides rules-based authorization decisioning with clinical criteria libraries (InterQual, MCG) for medical necessity review. Routine authorizations matching clinical criteria are auto-approved. Complex cases are routed to nurse reviewers with clinical context from the member’s EHR record, enabling faster and more accurate decisions. Denial letters include specific clinical criteria citations and appeal instructions.
For health systems operating their own insurance products, premium billing is a core revenue function. Covenant manages member premium invoicing across individual, group, and government-sponsored plans. Payment processing handles check, ACH, and credit card transactions with automated posting. Delinquency management tracks past-due premiums with configurable grace periods and generates disenrollment notices when required by regulatory timelines.
Provider-sponsored health plans face the same regulatory reporting requirements as commercial insurers: CMS Star Ratings for Medicare Advantage, HEDIS quality measures, Medical Loss Ratio (MLR) reporting, state insurance department filings, and NCQA accreditation standards. Covenant automates regulatory reporting from operational data, providing continuous visibility into Star Rating trajectory, HEDIS measure performance, and MLR compliance rather than annual batch calculations.
A provider-sponsored Medicare Advantage plan with 84,000 members deployed Covenant to replace a legacy Tapestry implementation that required 14 FTEs to maintain. The auto-adjudication engine achieved 94% clean claims processing without human intervention, reducing claims staff from 14 to 6. Fee schedule modeling identified $8.4 million in contract optimization opportunities during the first renewal cycle. Continuous HEDIS tracking and automated gap closure campaigns through Clarion Meridian improved the plan’s CMS Star Rating from 3.5 to 4.5 stars, qualifying for quality bonus payments worth $12 million annually.
We are a health system that operates a Medicare Advantage plan. We are both the provider and the payer. Our old Tapestry implementation required 14 people just to process claims and maintain contracts. Covenant automated 94% of our claims adjudication and gave us fee schedule modeling that identified eight million dollars in contract optimization opportunities we did not know we were leaving on the table. But the real transformation was in Star Ratings. Continuous quality tracking replaced annual batch calculations, and we went from 3.5 to 4.5 stars in one measurement year. That is twelve million dollars in quality bonus payments. The platform paid for itself before the first renewal.
See Covenant configured for your organization.