SIMPLIFY OPERATIONS. MAXIMIZE PERFORMANCE.
Powering End-to-End Health Plan Performance
COPE Health Solutions is the single, accountable partner behind your entire health plan operation — product, network, sales, enrollment, claims, contact center, medical management, finance, and compliance. Outsource one function or the whole operating model. One hand to shake, one connected platform, one team accountable for the outcome.
Your partner for performance
One Partner. One Platform. Total Alignment.
Health plans don’t lose ground to one problem — they lose it to fragmentation: a network vendor here, a TPA there, a point solution for Stars, another for risk adjustment, none of it talking to each other, and no one accountable for the whole. We replace that patchwork with a single accountable operating partner. Every function we deliver — whether run natively on our platform or orchestrated through the technology and operations partners we manage on your behalf — sits under one unified data and workflow layer in ARC, one SLA, and one team accountable for the outcome. Our approach delivers:
- A single accountable partner across as much — or as little — of your operation as you need, with the flexibility to expand scope as your priorities change
- Protected margin by targeting the utilization, risk adjustment, and cost drivers that erode MLR
- Faster quality and Stars performance through unified data and automated workflows, not fragmented point solutions
- Reduced administrative and clinical burden, unlocking capacity instead of adding headcount
- A better experience for members and providers, through streamlined, coordinated processes
WHERE TO START
Three Ways In. One Platform to Grow Into.
Most health plans don’t start with the full platform — they start with the problem costing them the most right now. Our solutions meet you at that entry point, and each one runs on the same platform, allowing scope to expand without switching partners.
Quality Clear Gaps
Close care gaps. Move quality performance. Fast.
- Close HEDIS/Star gaps in weeks, not the next measurement year
- ARCi, our agentic AI layer, surfaces which members and measures move your rating fastest, so effort goes where it pays off
- Built for measurable Star/quality movement, not another compliance dashboard
Margin Improvement
Protect your MLR. Strengthen risk accuracy. Reduce avoidable cost.
- Recover MLR points by catching risk and utilization leakage before it hits the P&L
- Share downside risk with us where it fits, instead of paying for effort regardless of outcome
- Engage one team to run analytics, medical management, and risk adjustment together, so nothing falls in the seams between vendors
Health Plan Operating System
The full operating system to run your plan. Delegate as much as you need.
- Run a full health plan operation without adding headcount
- Take routine work off your team’s plate from day one with our agentic AI layer
- One accountable partner, one contract, managing the mix of functions you delegate
Capabilities
One Hand to Shake, Across Every Function of Health Plan Operations
This is the full breadth of what we bring to bear for your operation — delivered directly by our team, or orchestrated through our vetted network of technology and operations partners, all under a single contract and single point of accountability. ARC sits above every domain as the unified data, workflow, and oversight layer. Whether you delegate one function or the whole operation, nothing becomes another silo to manage, and no vendor relationship becomes yours to untangle.
Medical Management
We manage utilization and care to improve outcomes and protect margin.
- Medical policy management and full-service utilization management
- NCQA Accredited Care management and population health management
- Predictive analytics and reporting
Quality
We manage quality performance end to end — design, oversight, and improvement, not just measurement.
- Star Ratings, HEDIS, and state/regulatory quality program management
- Quality program design, governance, and ongoing oversight
- Care gap identification and closure, powered by ARCi
Financial Management
We manage the financial mechanics of risk — from capitation to actuarial services.
- Capitation and shared risk, risk adjustment
- Cash management, finance & accounting, general ledger
- Actuarial services
- MMR processing and recalculation
Data, Reporting & Compliance
We turn fragmented data into a single, compliant source of truth.
- Operational reporting and QA
- Audit and compliance support
- FHIR-enabled interoperability and EMR workflow integration
- Enterprise data warehouse and comprehensive analytics
Enrollment & Billing
We handle every touchpoint from application to premium reconciliation.
- Enrollment, member management, and group membership
- Premium billing and enrollment/billing reconciliation
- Fulfillment, member materials, and case install
- Medicare enrollment portal and member portal
Claims
We process claims accurately, on time, and at scale — from intake through payment.
- Trading partner setup, claims data entry, and adjudication
- Payment disbursement and EOB/EOP
- COB administration, subrogation, and TPL
- Encounters and accumulator management
Contact Center
We field every member and provider call, powered by AI-enabled service.
- Member and provider service calls, appeals & grievances
- Outbound call campaigns and language translation
- AI digital agents and IVR
Product Development
We design, price, and file the products that drive your growth strategy.
- New product definition, pricing, and product filing
- Market trend and segment analysis
- Benefit coding
Network Management
We build and manage the provider network your plan runs on.
- Network strategy, maintenance, and provider relations
- Credentialing and contract loading
- Provider directory management and fee schedule configuration
TAKE A TOUR
Experience ARC in Action
ARC is the platform running underneath every capability above — turning fragmented data into the analytics, workflows, and agentic AI that drive oversight, provider action, and continuous improvement across your entire operation.
Recognition & Accreditation
Client Results
Recent Client Impact
MEET ARCi
ARCi™: The Agentic AI Layer Behind Every Function We Run
ARCi isn’t a bolt-on tool — it’s the AI layer behind how we orchestrate and oversee every function we run for our health plan partners, from product and network to claims, enrollment, contact center, and compliance. It augments your teams (or ours, running on your behalf) to reduce burden and create scale, automating routine work and surfacing what needs attention so people can focus on higher-value decisions.
Insights
Helping Healthcare Leaders Navigate a Rapidly Evolving Healthcare Landscape
Browse our library of latest thinking for insights and analysis to guide your value-based care and population health management strategy.
ON-DEMAND WEBINAR
Navigating the Fog: How Health Plans Can Succeed Through Policy and Market Shifts
Health plans are preparing for a volatile stretch ahead. Between shifting federal policy, tightening margins, and rising pressure to modernize operations, leaders need more than predictions. They need a clear understanding of what’s ahead. This webinar brings together experts from COPE Health Solutions, HealthAxis, and Sheppard Mullin to help plan a confident path forward.