Garnet Care

Our health care operations practice is delivered through Garnet Care. Our focus is to ensure your organization has “Best-in-Class” regulatory industry standards in place with effective monitoring and oversight tools.

Areas of Specialization
New Program Start-Up & Expansions | Business Process Improvement & Operational Excellence | Program & Vendor Oversight | Compliance, QA/IVV | Medicaid & Medicare | Compliance Repository

Why Garnet Care for Health Care Operations
We help you work smarter, not harder. Garnet Care’s subject matter experts have over 35 years of industry experience. Our proven methodology focuses on people, process, and technology. And we leverage unmatched data analytics to optimize your operations and systems…yielding cost savings and successful audit outcomes.

We support: Health Plans, BPOs, TPAs, State Public Sector & Federal Organizations, Hospitals, Healthcare Service Providers, ACOs.

Service Offerings

What we do Client outcomes
Develop and implement:

  • Regulatory Matrix to establish operational and system requirements in accordance with CMS/State regulations
  • Functional area workflows
  • Business and system requirements
  • Functional area test case scenarios
  • CMS/State/Vendor data file exchanges
  • Policy and Procedures
  • Desktop Level Procedures (DLPs)
  • Training Materials for functional areas
  • Regulatory and Internal Operational Reporting
  • Executive Dashboards
  • Audit Universe Development and Testing
  • Post Go-Live support
Proven results:

  • Compliant Operations aligned with CMS and State Regulations
  • Effective Operational Processes and Controls
  • Successful Regulatory Audits
  • Reduced Risk of Non-Compliance findings
  • Regulatory Reporting Readiness
  • Program insight at Executive and Operational levels
  • Resources that are prepared, confident and knowledgeable for Go-Live support
  • Reduced Risk of Member and Provider Complaints, Appeals and Grievances
What we do Client outcomes

  • Operation and System Compliance Risks
  • Resource Utilization Constraints
  • Process Gaps and Remediation to enhance Operation and System automation
  • Provider Network Set Up and Configuration concerns
  • Insourcing and Outsourcing opportunities to increase company revenue and process efficiencies
  • Interdepartmental data exchange deficiencies


  • Early warning sign strategies to minimize Operation Inventory backlog
  • Robotic Process Automation (RPA)
    • Repetitive Simple to Complex Tasks
  • Validation tools to ensure accurate Provider Configuration, Contract Rates, and Provider Data

  • Eligibility determination
  • Eligibility data accuracy and processing time
  • Claims payment accuracy and processing time
  • Appeals and Grievances processing time
  • Provider Network claim pends and adjustments
  • Provider match rate and payment accuracy
  • Provider Credentialing processes and OIG Check
  • Quality of products delivered to patients and members
  • Member, Provider and Patient satisfaction
  • Regulatory reporting
  • Operations and leadership reporting
  • Seamless interdepartmental data exchange
What we do Client outcomes

  • Compliance Risks
    • Regulatory
    • Contract Service Level Agreements (SLAs) and Performance Guarantees (PFGs)
    • Data Exchange Gaps and Remediation efforts


  • Reconciliation tools to reduce the risk of Data Discrepancies
    • Eligibility
    • Provider
    • Claims Payment
    • Encounters
  • Audit Universe Validation
  • Payment Integrity & Program Validation Tools
Proven results:

  • Empower our clients to control costs
  • Reduce risks to ensure effective service delivery
  • Improved Program outcomes, Managed Oversight and Quality Controls
    • Compliance and Data Exchange Integrity
    • Member and Provider Network satisfaction
    • Claims payment accuracy and timeliness
    • Appeals and Grievances accuracy and timeliness
    • Plan Payments and accurate Risk Adjustment Factor Scores (RAF)
  • Increased Audit Universe Data Integrity
  • Improved Fraud, Waste and Abuse Detection
What we do Client outcomes
Identify and implement:

  • Standardized processes and tools to support/create:
    • Ongoing Quality Assurance Program
    • IV&V Program
    • Regulatory Reporting
  • Perform Mock Audits:
    • Determine Compliance Risks to prevent future Regulatory Corrective Action Plans (CAPs)
    • Identify Cross Functional Process Improvements
  • Audit Support:
    • Review/Develop Audit Universes
    • Prepare Responses to Audits and the documentation requested
    • Develop, Execute and Oversight of Corrective Action Plans (CAPs)
  • Negotiate settlements as necessary
Proven results:

  • Reduced Audit findings and Compliance costs
  • Improved Process Controls affording smoother Regulatory Audits
  • Alignment with CMS and State Regulations.
  • Increased CMS STAR Ratings
  • Established effective and repeatable oversight and quality control tools
  • Regulatory reporting readiness
  • Reduced Member and Provider Complaints
  • Decreased Appeals and Grievances
  • Identification of operational gaps
  • Opportunities for resource training

Product Offerings

Offerings Organization benefits
This Medicare Eligibility and Plan Payment Reconciliation Tool that manages, reconciles, and reports the following CMS data files:

  • DTRR (Daily Transaction Reply Report)
    • Medicaid & LTI Indicators
  • MMR (Member Maintenance Report)
  • PPR (Plan Payment Report)
  • LEP (Late Enrollment Payment)
  • LIS (Low Income Subsidy)
  • Monthly Premium Withholding Report (MPWRD) Data File

Provides CMS with timely and accurate information regarding the beneficiaries’ enrollment, disenrollment, special membership status, and State and County Code changes.

Exports Reporting and Remediation/Aging tracking that summarizes:

  • Discrepancy type and aging
  • Plan vs CMS discrepancy
  • Timing issues
  • Research and remediation recommendations
  • Executed remediation actions

Retroactivity submissions (Category II and III)

Supports CMS required data processing in an efficient automated manner:

  • Daily and Monthly Reconciliation of the following Data:
    • Eligibility (incl. DTRR)
    • Plan Payment
    • Quarterly Attestations
  • Provides an effective tool to support identifying, tracking, and managing discrepancies between CMS and Plan Data to increase:
    • Eligibility and Plan Payment accuracy
    • CMS payment timeliness
    • Prompt remediation of eligibility and payment data discrepancies
  • Storing and updating of CMS Risk Adjustment Factor scores (RAF)
  • Identification of Operational Issues:
    • Processor
    • System Automation
Offerings Organization benefits
An Automated Regulatory Data Repository that stores, manages, and automates the upload for ongoing CMS and State Regulatory requirement updates and changes:

  • Updates Regulatory changes through an Automated upload to this Repository from any file format
  • Exports reporting that summarizes Process Change impact by Functional Area to allow for more efficient and timely operation and system changes to occur
  • Reporting will summarize the Operational changes required to meet the Updated/New Regulations
  • Ongoing Financial Savings on Resources Costs to support these efforts
  • Reduces Compliance Risks Which Decreases CMS Financial Penalties
  • Streamlines Regulatory changes to maintain Compliant Operations and Service Excellence
  • Identification of Member/Provider Materials impact
  • Supports Training/P&P Material Creation and Updates to existing
Offerings Organization benefits
A Regulatory Matrix that is a one-time Export of the current CMS and State Regulatory requirements as of a point in time.

This can be provided to Organizations as the starting point to manage all CMS and State Regulations to maintain manually ongoing.

  • One time Savings on Project Resource Costs
  • Establishes Compliant Operations for all Functional Areas
  • Initial Reduction of Compliance Risks
  • Affords the ability to create required materials while limiting internal research time:
    • Member and Provider Materials
    • Policy and Procedures
    • Training Material
  • Supports Workflow and Desk Level Procedure Creation Saving Resources Time and Costs.
Offerings Organization benefits
A Compliance Data Repository Tool that manages, reconciles, and reports Security Breaches and Privacy Issues:

  • Security Breaches and Privacy Issues
  • Training (Annual & up training) & P&P Tracking and Management
  • Operations Compliance Oversight, Monitoring & CAP remediation plan tracking, oversight & resolution
  • Mock CMS Audits

Streamlines Customized State and Federal Regulation reporting to different entities (HHS, CMS)

Compliance issues identification, tracking and management of Cycle Resolutions Timing and Aging, such as:

  • Employee terminations and re-hire and employee retraining
  • Member notifications
  • Member provided 1 year of credit monitoring
  • Media notifications
  • System corrections
  • Centralized Compliance tracking tools allow for:
    • Reduced compliance issues due to increased awareness
    • Increased data integrity
    • Timely Remediation and Reporting
  • Support confirming all Organizational/Operational P&Ps are in place and updated annually
  • Support CMS reporting of Annual required Training and uptraining because of any CAPs initiated by Compliance, Compliance issue CAP Plan tracking, reporting & results monitoring
  • Report CMS mock Audit Results which assist Plans in identify how they would perform during a CMS initiated audit & assist with GAP identification and resolution
Offerings Organization benefits
Capella Care is a Mobile App for Family Caregivers that reduces the stress and increases the effectiveness of family care.  We’ve combined the best caregiving tools into one app, allowing family caregivers to spend more time with the people they love and less on logistics, organization, confusing search results, and issues from poor communication.

Our goal is to bring together families and friends to reduce headaches and stress of being a family caregiver. Your focus is your Loved One, the Care Receiver. Capella Care enables you to keep track of every aspect of their healthcare.

Capella Care allows a Primary Caregiver to coordinate with family and friends to provide care through the following main functions:

  • Collective notetaking, scheduling and managing appointments.
  • Conducting medical research through the National Institute of Health’s (NIH) MedlinePlus curated library of health information.
  • Documenting symptoms and prognosis.
  • Preparing for doctor’s visits by recording questions and concerns beforehand and recording answers and notes afterwards.

Storing important documents, medications, lists, and test results.

This Mobile App could be used by your patients and members as an added benefit and could be utilized to improve:

  • Patient and Member satisfaction
  • Coordination of Care
  • Medical and Utilization Management
  • Provider satisfaction

“We started Garnet Care health care operations because of the growing need for organizations to meet regulatory standards through effective monitoring and oversight. Our approach is 360, and success for us is ensuring you have the right people, processes, and technology to maintain standards and and operate with sustainable excellence.”

– Courtney Seypura, Practice Lead