Payer-provider interoperability and electronic prior authorization solutions

The TriZetto Provider Electronic Prior Authorization is designed to meet providers where they are—whether in large health systems or independent practices—by offering flexible, standards-based connectivity that integrates seamlessly into existing workflows. The solution empowers providers to automate prior authorization processes without disrupting their current systems or relationships:

• SMART on FHIR app submission from EMRs
  
  
• Direct API submissions from EMRs
  
  
• Extended FHIR connectivity to providers by supporting their existing clearinghouse relationships

Built for health systems and practices working to reduce prior authorization burden and replace manual fax- and portal-based submissions with EMR-embedded automation.

The TriZetto Payer Care Gaps Solution creates a single, streamlined ecosystem for clinical documentation exchange, reducing administrative burden and improving interoperability by enabling seamless, bidirectional exchange of quality measure data between payers and providers to address gaps in care. The solution provides near real-time, actionable information to empower healthcare stakeholders to deliver high-quality care, leading to better health outcomes and higher patient satisfaction.

Helps payers close care gaps and improve HEDIS and quality measure performance through bidirectional, real-time clinical data exchange.

The TriZetto Payer Clinical Data Exchange Solution delivers a unified, dual-sided workflow for solicited attachments supporting both prior authorization and claims processes. This solution aligns with HL7 Da Vinci CDeX implementation guide standards:

• Automates task-based requests and submissions using API for prior authorization and claims documentation
  
  
• Supports LOINC-coded requests, enabling precise data targeting and reducing unnecessary data exposure
  
  
• Integrates with payer core systems, including Facets and QNXT, and care management platforms such as CareAdvance
  
  
• Accepts structured and unstructured formats, ensuring flexibility across provider systems
  
  
• Enables efficient clinical and administrative decision-making through seamless FHIR-based exchanges

Streamlines solicited clinical attachments for prior authorization and claims, reducing administrative back-and-forth between payers and providers.

TriZetto Provider Clinical Data Exchange Solution improves payer-provider collaboration by:

• Integrating real-time payer data into EHRs to support value-based care and measurable outcomes like quality metrics, care gap closures and population health improvements
  
  
• Automating workflows to dramatically reduce administrative tasks, alleviate staff burnout and improve operational efficiency
  
  
• Improving interoperability with FHIR-based APIs for secure, seamless data exchange across systems
  
  
• Bridging the payer-provider gap by enhancing communication and aligning workflows for fewer disputes and faster decisions
  
  
• Reducing fragmentation through standardized APIs and eliminating outdated tools like fax machines and payer portal

Helps provider organizations reduce administrative burden by replacing outdated fax and portal workflows with FHIR-based payer data integration.