Cotiviti Holdings, Inc.

What Cotiviti Holdings, Inc. does

Cotiviti Holdings, Inc. is a private, PE-backed healthcare data infrastructure company that provides payment integrity, risk adjustment, quality measurement, and interoperability solutions to U.S. healthcare payers, providers, government programs, and retailers. Founded in 1979 and headquartered in South Jordan, Utah (with offices in Atlanta and global operations across Canada, India, Australia, Philippines, and Mexico), Cotiviti claims to serve all 25 of the largest U.S. health plans, processing 3.5B+ claims annually and identifying $10B+ in inappropriate payments in 2025. The company operates a global workforce of 9,000+ employees.

The company's platform is organized into three interconnected solution areas: Payment Integrity (claim accuracy, payment policy management, coding validation, dental claim accuracy, clinical chart validation, COB validation, FWA pattern review, contract compliance, data mining); Health Enablement (Quality Intelligence, Star Intelligence, Medical Intelligence, DxCG Intelligence for risk adjustment, Engagement Hub, and Eliza for member engagement); and Interoperability (EDI Gateway, FHIR Gateway, Smart Trading, Transaction Management, Enrollment Management, Prior Authorization, Member Consent Service, Electronic Claims Attachments). The Interoperability suite was substantially expanded through the March 2025 acquisition of Edifecs, a healthcare interoperability pioneer. Underlying technology includes AI-enabled workflows, predictive analytics, NLP for clinical documents, and standards-based data exchange (EDI X12, HL7 FHIR). Cotiviti has held 25 consecutive years of NCQA HEDIS certification, HITRUST CSF certification, and CMMI Level 3 designation.

Cotiviti generates revenue primarily through subscription and recurring enterprise contracts with healthcare payers, with transaction-fee components in its retail recovery audit business. GTM is direct enterprise field sales, complemented by a client portal (MyCotiviti) and the Cotiviti Interoperability University training program. The company is owned by Veritas Capital and KKR following a May 2024 recapitalization, and previously operated as a public company (NYSE: COTV) before being taken private by Veritas-backed Verscend in August 2018 for $4.9 billion. No current revenue, ARR, or valuation is publicly disclosed.

Name

Cotiviti Holdings, Inc.

Legal name

Cotiviti, Inc.

Website

https://cotiviti.com

Company type

Private

Founded year

2016

Operating status

Operating

Short description

Cotiviti is a private, PE-backed healthcare infrastructure company providing payment integrity, risk adjustment, quality measurement, and interoperability solutions to all 25 of the largest U.S. health plans, processing 3.5B+ claims annually and identifying $10B+ in inappropriate payments across 300M+ members.

Ownership category

akta.pro rank

Product category

Healthcare Payment Integrity and Analytics

NAICS

Computing Infrastructure Providers, Data Processing, Web Hosting, and Related Services (518), Computing Infrastructure Providers, Data Processing, Web Hosting, and Related Services (518210), Direct Life, Health, and Medical Insurance Carriers (52411)

SIC

Services-Prepackaged Software (7372), Services-Health Services (8000), Services-Computer Programming, Data Processing, Etc. (7370)

akta.pro primary industry

Data Aggregation, Interoperability & APIs for RPM (FHIR/IoMT Gateways) (HLACAFAO)

akta.pro secondary industries

Eligibility & Benefits Verification (HLACACAD), Cost of Care, Spend Analytics & Financial Performance Management (HLACAHAJ)

Keywords

• Healthcare payment integrity
• Healthcare interoperability
• Payment accuracy solutions
• Healthcare data analytics
• Clinical data exchange

Headquarters

HQ city

Atlanta

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2B

Offering type

Software

Cost components

Personnel, Technology or R&D, Operations, Marketing or Sales, Infrastructure, Others

Revenue model

1. Payment Integrity Solutions: Pre-payment integrity solutions helping health plans identify and prevent improper payments before they occur. Serves 23 of top 25 national payers with over $10 billion in claims payment errors identified and recovered in 2025.
2. Interoperability Solutions: EDI Gateway, FHIR Gateway, Smart Trading, Transaction Management, Prior Authorization, Enrollment Management, Member Consent Service, and Electronic Claims Attachments for healthcare data exchange
3. Health Enablement Solutions: Risk adjustment, quality and Stars, member engagement solutions transforming data into action across healthcare financial and clinical operations
4. Retail Solutions: Data management and recovery audit services to the retail sector improving business outcomes

Pricing tiers

Go-to-market motion1 record

Distribution channels3 records

Marketing channels8 records

Core offering

Cotiviti provides a healthcare infrastructure platform delivering analytics-driven software solutions across three interconnected areas: Interoperability (EDI Gateway, FHIR Gateway, and data exchange), Health Enablement (risk adjustment, quality measurement, Star Ratings, and member engagement), and Payment Integrity (pre- and post-payment accuracy, coding validation, and fraud detection). The company's products process over 3.5 billion claims annually for 25 of the 25 largest U.S. health plans, employing AI-powered analytics to identify $10B+ in inappropriate healthcare payments each year.

Product overview

Cotiviti is a healthcare infrastructure platform providing data-driven technology solutions organized into three interconnected solution areas: Interoperability (acquired Edifecs brand), Health Enablement, and Payment Integrity. The Interoperability suite includes EDI Gateway, FHIR Gateway, Smart Trading, Transaction Management, Enrollment Management, Prior Authorization, Member Consent Service, and Electronic Claims Attachments. Health Enablement encompasses Quality Intelligence, Star Intelligence, Medical Intelligence, DxCG Intelligence, Engagement Hub, and Eliza (member engagement). Payment Integrity includes Claim Accuracy, Payment Policy Management, Coding Validation, Clinical Chart Validation, Dental Claim Accuracy, COB Validation, FWA Pattern Review, Contract Compliance, Data Mining, and Claim Pattern Review. Cotiviti also offers training through Cotiviti Interoperability University. The platform processes 3.5B+ claims annually and serves 25 of 25 largest U.S. health plans.

Differentiator

Problem solved

Functional benefit

Brands

• Edifecs: Healthcare interoperability solutions including EDI Gateway, FHIR Gateway, and data exchange platforms. Named 2026 Best in KLAS for CMS Payer Interoperability.

Products and services

• EDI Gateway A fully-managed EDI gateway that ingests healthcare data in various formats and transforms it into standardized HIPAA-compliant X12 transactions, supporting secure, validated exchange between trading partners.
• FHIR Gateway A standards-based API exchange platform using HL7 FHIR that consolidates CMS-mandated APIs into a single flexible interface, bridging modern FHIR APIs with legacy EDI systems.
• Smart Trading A modular integration platform for exchanging transactions with external trading partners and internal systems, leveraging over 30,000 pre-built templates to support data validation, transformation, and routing.
• Transaction Management An AI-powered centralized hub for tracking data exchange insights across EDI transactions, with natural-language transaction search and AI-enabled correction suggestions serving 75+ customers.
• Enrollment Management A secure, scalable platform automating enrollment intake, validation, reconciliation, and workflow management across multiple lines of business, managing 17M+ members.
• Prior Authorization A unified prior authorization solution that consolidates and routes requests from any channel (EDI, HL7 FHIR, portals, fax) into a single workflow with AI-enabled intake.
• Member Consent Service A centralized platform for capturing, storing, and managing member consents for PHI disclosure, supporting compliance with CMS-0057-F, 42 CFR Part 2, and state privacy mandates.
• Quality Intelligence An NCQA-certified quality measurement and reporting solution that supports HEDIS measure logic, systematic sample processing, and Star Ratings optimization for health plans.
• Star Intelligence A predictive analytics solution launched in October 2022 that enables Medicare Advantage plans to forecast and improve Star Ratings performance through data-driven insights.
• DxCG Intelligence A risk adjustment analytics solution with clinical and pharmaceutical classification systems supporting accurate Hierarchical Condition Categories (HCC) coding and risk-score prediction.
• Engagement Hub A member engagement solution launched in January 2025 that enables health plans to drive targeted outreach and improve member health outcomes.
• Eliza An AI-powered member engagement platform enabling personalized communication and outreach to improve health outcomes for health plan members.
• Claim Accuracy A pre-payment accuracy solution ensuring accurate claims processing through data validation and business rules across the claims lifecycle.
• Payment Policy Management A platform for managing healthcare payment policies and ensuring consistent policy application across claim adjudication.
• Coding Validation A medical coding accuracy solution that validates ICD-10, CPT, and HCPCS codes to ensure proper claim reimbursement.
• Dental Claim Accuracy A specialized dental claims validation solution helping dental plans reduce claim spend and achieve accurate adjudication; enhanced version launched August 2026.
• FWA Pattern Review A fraud, waste, and abuse detection solution that identifies abnormal patterns and suspicious provider behavior in healthcare claims data.
• COB Validation A coordination-of-benefits validation solution ensuring claims are paid by the correct insurer, with an AI-enabled proactive variant launched August 2026.
• Data Mining An advanced analytics solution identifying overpayments and billing-pattern anomalies through comprehensive claims data analysis.
• Contract Compliance A healthcare contract compliance solution ensuring payer-provider agreements are honored in claims processing.
• Edifecs Healthcare interoperability software brand acquired by Cotiviti in March 2025, providing EDI Gateway, FHIR Gateway, Smart Trading, and related data management platforms for payers and health systems.
• Cotiviti Interoperability University An expert-led training platform for the Cotiviti product ecosystem, delivered through virtual instructor-led, self-paced video, and open enrollment formats covering SpecBuilder, MapBuilder, XEngine Server, and Transaction Management.

Quantifiable outcome

• $10B+ inappropriate payments identified and recovered annually
• +4 more outcomes

Named customers2 records

Segments5 records

Ideal customer profiles4 records

Technology focussed Yes

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

AI capability8 records

Feature12 records

Partnerships

Nine partnerships are on record, tiered core and strategic.

• EdifecscoreStrategic or Co-development Partner · 31 March 2025Cotiviti completed acquisition of Edifecs, a pioneer in healthcare data and interoperability. Edifecs provides market-leading technology enabling payer and health system customers to unlock greater value with healthcare operations solutions and data management platform. The acquisition was announced on February 10, 2025 and completed on March 31, 2025, creating one of the most comprehensive interoperability solution portfolios in healthcare.
• Verscend TechnologiescoreStrategic or Co-development Partner · 19 June 2018Verscend Technologies (formerly Verisk Health), a portfolio company of Veritas Capital, acquired Cotiviti for $4.9 billion. The combined business operated as a private healthcare IT company with complementary solutions across payment accuracy, risk adjustment, quality improvement, and population health.
• General Dynamics Information TechnologystrategicStrategic or Co-development Partner · 6 February 2018Verscend Technologies acquired commercial health insurance payer-focused products from General Dynamics Information Technology, strengthening its fraud waste and abuse detection capabilities and payer quality analytics and reporting solutions. Completed March 2, 2018.
• HL7 FHIRcoreTechnology or IntegrationEdifecs, a Cotiviti business, is an active participant in HL7 Fast Healthcare Interoperability Resources (FHIR) working groups and a founding member of the HL7 Da Vinci Project Interoperability Standards Group focused on adoption of HL7 FHIR standards.
• The Sequoia ProjectstrategicTechnology or IntegrationEdifecs, a Cotiviti business, is an active participant in working groups within The Sequoia Project, supporting interoperability standards adoption in healthcare.
• WEDIstrategicTechnology or IntegrationEdifecs, a Cotiviti business, is an active participant in WEDI working groups, including co-chairing the WEDI Attachments Workgroup supporting stakeholders in meeting compliance deadlines for claims attachments modernization.
• CAQH COREstrategicTechnology or IntegrationEdifecs is a CAQH CORE-authorized testing vendor providing CORE certification testing services since 2006, supporting administrative simplification in healthcare.
• NCQAcoreTechnology or IntegrationCotiviti's Quality Intelligence solution earned NCQA HEDIS Certified Measures status, with the company achieving 25th consecutive year of HEDIS certification in 2025.
• CMS (Centers for Medicare & Medicaid Services)coreTechnology or IntegrationCMS uses Edifecs Onboarding & Testing Cloud Service (OTCS) platform as part of its Administrative Simplification Enforcement and Testing Tool (ASETT). Cotiviti GOV Services awarded CMS RAC contracts for Region 3, Region 4, and Region 5.

Scale indicators15 records

Recent moves8 records

Expansion highlights6 records

Direct peers

• Conduent: Conduent provides healthcare claims administration, payment integrity, and customer-experience BPO services for payers. Its payment integrity and claims-processing offerings overlap directly with Cotiviti's Payment Integrity solutions.
• CitiusTech: CitiusTech provides healthcare technology services and analytics for payers, providers, and life sciences, including payment integrity and interoperability solutions. It is comparable to Cotiviti's technology services and analytics delivery model.
• Change Healthcare (now part of Optum): Pre-merger Change Healthcare was the leading independent healthcare interoperability and payment network, competing head-to-head with Edifecs on EDI/FHIR gateway and with Cotiviti on claims accuracy and analytics. Acquired by Optum in 2022.
• Inovalon: Inovalon provides payer analytics, risk adjustment, and quality measurement platforms directly comparable to Cotiviti's Health Enablement suite (Quality Intelligence, Star Intelligence, DxCG). Privately held by Nordic Capital since 2021.
• Availity: Availity operates a healthcare interoperability network connecting payers and providers via EDI/FHIR data exchange, directly competing with Cotiviti/Edifecs on administrative data exchange, prior authorization, and eligibility workflows.
• SS&C Health: SS&C Health (formerly DST Health Solutions) provides payer technology platforms for claims administration, benefits management, and member engagement. It competes with Cotiviti across health-plan operational systems and analytics.
• LexisNexis Risk Solutions (Healthcare): LexisNexis Risk Solutions provides payer-focused data, identity, and analytics products including coordination of benefits, payment integrity, and fraud detection. It is a direct competitor to Cotiviti's COB validation, FWA Pattern Review, and Data Mining products.
• Optum (UnitedHealth Group): Optum operates payment integrity, claims editing, interoperability, and analytics businesses that directly compete with Cotiviti's three solution areas. As the technology arm of UnitedHealth, Optum also competes through in-house bundling across PBM and care delivery that standalone peers cannot match.

Broad incumbents

• Health Catalyst: Health Catalyst is a healthcare data and analytics platform serving providers, payers, and ACOs. It overlaps with Cotiviti's Quality Intelligence and risk adjustment analytics but is more provider-centric and less focused on payment integrity.

Emerging players

• Datavant: Datavant focuses on healthcare data exchange, de-identification, and linking across payers, providers, and life sciences. It competes in the data-interoperability layer adjacent to Cotiviti/Edifecs and is growing as a tokenization/privacy-preserving data partner for payer analytics.

Market position

Weaknesses5 records

Competitive moat6 records

Key risks6 records

Key highlights7 records

Customer concentration

• LinkedInlinkedin.com/company/cotiviti

Compliance6 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles7 records

Subsidiaries1 record

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about Cotiviti Holdings, Inc.