ELEMENTS PRODUCT SUITE

• TRIZETTO® ENROLLMENT ADMINISTRATION MANAGER AND TRIZETTO ENROLLMENT ADMINISTRATION MANAGER WORKFLOW

  TriZetto® Enrollment Administration Manager (EAM), along with the capabilities of TriZetto®Enrollment Administration Manager Workflow, support health plans along the path from enrollment to acceptance. EAM streamlines the process to enroll your members in Medicare Advantage. The product is constantly updated to reflect CMS regulatory changes and can pass data to both the Facets® and QNXT™ platforms, making it a critical part of a complete solution. The workflow capabilities manage the overall enrollment process, improving visibility and tracking throughout the enrollment lifecycle.

  With TriZetto Enrollment Administration Manager and TriZetto Enrollment Administration Manager Workflow you can:

  • Initiate new enrollments, PBP changes, disenrollments and member changes from multiple channels including batch, web service and user entry.
  • Leverage comprehensive validations of enrollment and member change transactions to streamline enrollment processes to maximize acceptance rates and minimize unnecessary manual work.
  • Automate member eligibility verification directly with CMS Batch Eligibility Query (BEQ).
  • Meet Part C and Part D enrollment reporting requirements including robust processing of daily and special Transaction Reply Reports (TRR) in applying member updates.
  • Enforce enrollment related CARA Legislation.
  • Gain a clear view of daily enrollment work in progress.
  • Enable compliance with CMS regulations.
  • Automate the routing and assignment of work items based on specific roles, queues and priorities for issue enrollment and resolution.
  • Integrate enrollment data with QNXT, Facets or other third party core administration applications for billing, claims processing and member services.
• FINANCIAL RECONCILIATION MANAGER

  TriZetto® Financial Reconciliation Manager (FRM) streamlines and automates the process of reconciling the amount plans have been paid by CMS with the member payments received, comparing plan and CMS membership data to flag and determine the impact of discrepancies. The system prioritizes inconsistencies with the greatest financial impact and provides key data to resolve discrepancies quickly.

  With Financial Reconciliation Manager you can:

  • Use one system for Medicare Part C and Part D payment reconciliation by member or Plan/PBP.
  • Identify eligibility, member demographic, special status, low income, out of area and payment discrepancies.
  • Correct your plan’s internal data system and submit corrections to CMS via the Retroactive Processing Center.
  • Assist the management of work assignments, workflow management and discrepancy aging.
  • Ensure that your organization has the tools to remain in compliance with CMS regulations for financial reporting.
• TRIZETTO® ENCOUNTER DATA MANAGER™

  TriZetto® Encounter Data Manager™ (EDM) supports submission requirements and provides functionality to help our clients meet applicable compliance expectations, improve revenue and reduce overhead. EDM provides a configurable and scalable encounter management solution that produces agency compliant encounter transactions, while enforcing submission rules to help prevent non-compliant transactions from being submitted to CMS, Commercial Exchange or state agencies.

  With Encounter Data Manager you can:

  • Reduce costs associated with inaccurate or incomplete data by providing quick and timely resolution of submission errors.
  • Capture accurate data from multiple sources.
  • Gauge potential financial mismatches and potential loss of revenue from CMS, Commercial Exchange or state agencies.
  • Reduce the need for complex customization and state-specific solutions with built-in client configuration.
  • Access aggregated and detailed encounter management information.
  • Enhance business processes and provide transparency in the encounter life-cycle.
• TRIZETTO® CLAIMS DATA MANAGER

  TriZetto® Claims Data Manager (CDM) streamlines and simplifies your health plan’s requirement for submitting timely RAPS data for Medicare Advantage members. CDM is a configurable and scalable solution that produces agency compliant RAPS transactions, while enforcing submission, filtering and formatting rules to reduce non-compliant transactions from being submitted to CMS.

  With Claims Data Manager you can:

  • Edit pre-submissions for improved CMS acceptance.
  • Convert claims data into RAPS format.
  • Create batch files for Palmetto Customer Service and Support Centre (CSSC).
  • Load and reconcile RAPS response files.
• TRIZETTO® RISK SCORE MANAGER

  TriZetto® Risk Score Manager (RSM) analyzes data submitted by Claims Data Manager and Encounter Data Manager to calculate the risk scores your health plan can expect to be reimbursed based on the diagnoses submitted to CMS. It reconciles scores against monthly CMS data from the RAPS response files. With RSM, your health plan gains visibility into risk scores, which allows you to better forecast payments from CMS. RSM reconciles your RAPS and EDPS submissions to ensure the data submitted to CMS is accurate for both. It identifies missing adds or deletes by comparing RAPS Reply and MAO-004 files from CMS.

  With Risk Score Manager you can:

  • Identify member Hierarchical Condition Category (HCC) and Rx HCC by payment year and data collection.
  • Compare HCC information to CMS information to identify discrepancies.
  • Calculate Part C and Part D risk scores using plan, CMS demographics and HCC data.
  • Determine claim/diagnosis level RAPS in cases when CMS is missing accepted HCCs/Rx HCCs.
  • Provide detailed risk score and HCC-related management reports.
  • Utilize the RAPS response files and EDPS MAO-004 reports to compare the latest disposition of diagnosis codes at the member level.
• TRIZETTO® RISK ADJUSTMENT MANAGER

  TriZetto® Risk Adjustment Manager (RAM) aggregates claims, pharmacy and demographic data and runs it through algorithms to identify potential conditions a member may have. The results of the chart reviews—adds and deletes—are entered into RAM and extracted for submission via RAPS and EDPS to improve the overall accuracy of the data submitted to CMS. RAM runs a series of algorithms to identify additional diagnoses appropriate for members based on their claims history. With that information, your health plan can take action if additional diagnoses have been made by providers. With the data collected by RAM, health plans can request CMS to adjust risk scores for their Medicare Advantage members.

  With Risk Adjustment Manager you can:

  • Automate key processes from assessment of member data through creation of reports that support RADV audits.
  • Identify potential diagnoses by combining claims, pharmacy and demographic data.
  • Manage the workflow related to organizing prospective candidates for adjusted risk scores and requesting changes.
  • Track chart audit results on both Medicare Part C and Part D risk scores.
  • Conduct assessments on members by evaluating their health prior to claims submission.
• TRIZETTO® RISK ADJUSTMENT MANAGER FOR EXCHANGES

  TriZetto® Risk Adjustment Manager for Exchanges (RAMX) is a comprehensive workflow-based solution that helps health plans automate regulatory compliance and submission to the CMS EDGE server by aggregating patient data and identifying clinical suspects for risk review, coding resolution and formatting prior to submission. Applying advanced algorithms against claims data, pharmacy data, patient demographics, and care delivery demographics, RAMX enables payers to effectively recognize and address indications of inaccurate or unspecified patient conditions. Once your health plan has made the appropriate coding modifications to increase the accuracy and quality of the clinical data, files are automatically formatted for direct submission to the EDGE server. RAMX can also be integrated with your plan’s current solution for suspect generation.

  With Risk Adjustment Manager for Exchanges you can:

  • Increase the quality and accuracy of data submitted to CMS.
  • Identify clinical suspects for risk review and coding resolution.
  • Support regulatory compliance and timely submission of data to the EDGE server.
  • Detect issues for resolution and restitution prior to a RADV audit.
  • Allow suspect data comparisons at medical group, IPA and physician levels to identify provider education opportunities.
• TriZetto® PHARMACY DATA EVENT MANAGER

  TriZetto® Pharmacy Data Event Manager (PDEM) automates the workflow around pharmacy claim rejections from CMS, providing a clear view into the rejection type and ensuring they are corrected. PDEM identifies the issues, determines the reasons for rejection and corrects them for resubmission.

  With Pharmacy Data Event Manager you can:

  • Pre-screen records format and content per CMS edit criteria.
  • Create a CMS PDE file format for record submission.  
  • Track and update adjustment and deletion records for resubmission.
  • Import return files from CMS and Drug Data Processing System (DDPS) and update record statuses and error codes.
  • Allow users to edit and resubmit records from within the application.
  • Manage reports by file, batch, status, error code and plan benefit package.
• TRIZETTO® RX RECONCILIATION MANAGER

  TriZetto® Rx Reconciliation Manager (RxM) is a tool that helps plans fully understand the financial and reconciliation activity of CMS with regard to Medicare Part D. With this visibility, your plan can better anticipate payment adjustments and make changes for Part D benefits in the future.

  With Rx Reconciliation Manager you can:

  • Calculate and report on Medicare Part D retrospective reconciliation measures including low income cost sharing subsidy, reinsurance subsidy payment and risk corridor.
  • Harness the data processing and tracking capabilities of Financial Reconciliation Manager (FRM) for prospective revenue reconciliation and PDE Data Manager (PDEM) for PDE data processing, submission and management.