MCA Module
Medicare Coverage Analysis, rebuilt.
Automated gap detection between protocol, budget, and CTA. AI-powered payer classification with CMS cross-referencing. Proactive conflict detection before site activation.
The problem with manual MCA
Traditional Medicare Coverage Analysis is a labor-intensive process that relies on spreadsheets, tribal knowledge, and inconsistent documentation. The result: slow turnaround, audit risk, and rework.
- Manual line-by-line analysis across hundreds of procedures
- Inconsistent application of coverage criteria
- No traceability between decisions and source evidence
- Weeks of analyst time for a single protocol
- High risk of audit findings and compliance issues
How Engram's AI reasons across artifacts
The MCA Module applies structured reasoning to transform coverage analysis from an art to a science.
Ingest clinical artifacts
Upload protocols, budgets, CTAs, and billing grids. The system automatically extracts structured data from unstructured documents.
AI-powered analysis
Engram's reasoning systems analyze each procedure against Medicare coverage criteria, identifying coverage status, conflicts, and ambiguities.
Human review and decisions
Review flagged items, accept AI recommendations, override with rationale, and assign items for further review. Every action is tracked.
Export with traceability
Generate audit-ready deliverables with row-level rationale, evidence linking, and complete decision history.
The MCA Workbench
A structured interface for reviewing coverage determinations with flagged items, AI rationale, and complete decision traceability.
| Visit | Procedure | Freq | Plan Hint | AI Proposal | Status |
|---|---|---|---|---|---|
| Cycle 3 Day 1 | Brain MRI 70553 | 1 | Plan: Sponsor | AI: Medicare | Conflict |
| Screening | Informed Consent NA | 1 | Plan: Sponsor | AI: Sponsor | Auto-classified |
| Screening | Physical Examination 99204 | 1 | Plan: Medicare | AI: Medicare | Auto-classified |
| Screening | 12-lead ECG 93000 | 1 | Plan: Sponsor | AI: Sponsor | Auto-classified |
| Cycle 1 Day 1 | Disease Assessment (CBC) 85025 | 1 | Plan: Medicare | AI: Medicare | Auto-classified |
| Cycle 1 Day 1 | Bone Marrow Aspirate 38220 | 1 | Plan: Sponsor | AI: Medicare | Conflict |
| Cycle 1 Day 1 | PK Blood Draw 36415 | 1 | Plan: Sponsor | AI: Sponsor | Auto-classified |
| Cycle 1 Day 8 | Vital Signs 99211 | 1 | Plan: Medicare | AI: Medicare | Needs review |
Brain MRI
70553 - Cycle 3 Day 1
AI detected a critical 4-way mismatch. While the CTA states Sponsor pays for all MRIs, the Budget only reimburses 2 occurrences. The Protocol requires 3 MRIs (Screening, C3D1, EOT). Since this is the 3rd MRI and exceeds the budgeted amount, and is standard of care for this indication, AI proposes Medicare coverage to avoid unreimbursed costs.
Model cross-referenced CMS coverage rules and site standard-of-care policies.
- xCTA vs Budget Mismatch
- xProtocol frequency exceeds Budget
- xPayer Conflict: Sponsor (CTA) vs Medicare (AI)
Outcomes
Measurable improvements in speed, consistency, and compliance.
Speed
70-85%
of procedures auto-classified, reducing analyst time from weeks to hours
Reduced rework
Consistent logic eliminates coverage determination variability across studies
Audit readiness
Every decision includes rationale, evidence linking, and complete audit trail
Transform your MCA workflow
See how the MCA Module can reduce coverage analysis time while improving consistency and audit readiness.