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Streamline Claims Pricing Generates Operational and Medical Savings for Health Plan

The Challenge

A large, not-for-profit health plan wanted to transform its outdated multi-system pricing methodologies into a single unified and streamlined operation. The health plan had been using three different legacy platforms, operated by independent teams, to price and process its preferred provider organization (PPO) and health maintenance organization (HMO) claims. This separation of processes resulted in the assignment of different payment methodologies for identical services. In addition, the outdated systems affected the health plan’s ability to accommodate newer pricing models to keep pace with the evolving market. The health plan reached out to Cognizant for a solution to transform its costly and inefficient pricing operation into an effective and efficient model.

Our Approach

We implemented the TriZetto® NetworX Pricer® and NetworX Modeler® solutions for all three core legacy systems and integrated it with multiple systems. This enables a ‘single source of fact’ for the health plan to price claims across all lines of business with greater consistency and accuracy. In addition, we helped the health plan in a transformational project to reassess and simplify all of its historic payment policies and procedures in concert with its system migration. This accelerated migration expedited operational and medical cost savings and reduced the duration of running multiple systems in parallel.

Increased Accuracy and Efficiency Improved Provider Satisfaction

Using the TriZetto NetworX Pricer and Modeler solutions, the health plan significantly reduced the instances of both over- and under-priced claims—resulting in a net medical expense reduction of 1%. Their claims are now priced with greater precision and consistency to deliver operational and medical cost savings and improved provider relations.



CMS/Optum update implementation time from approximately three months to one week


2,500+ default fee schedule tables to 48