Please visit the COVID-19 response page for resources and advice on managing through the crisis today and beyond.
Meeting the complex data processing and compliance requirements of Medicare Advantage, managed Medicaid and Commercial Exchanges in a timely manner is critical to your success. Our TriZetto Elements® suite of capabilities extends the functionality of your core system with the features you need, providing critical capabilities from enrollment through risk adjustment to efficiently drive these lines of business forward.
Our standalone solutions integrate well together, with Facets®, QNXT™ and other core systems. With Elements products, it is easy to share information and speed processing.
With Elements you can:
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:
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:
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:
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:
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:
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:
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:
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:
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:
Our TriZetto Elements Enrollment Administration Manager (EAM) Workflow solution helps SelectHealth® process applications on a first-in, first-out basis while meeting CMS guidelines and compliance regulations.LEARN MORE
Our TriZetto Financial Reconciliation Manager (FRM) module enables SelectHealth to forecast financials more effectively and report plan information more accurately.LEARN MORE
Comprehensive, flexible and scalable core administrative solutions that enable the digital transformation required for success in the commercial market.
Supports the economic advantage and efficiency needed to administer an individual line of business and participate in public and private insurance exchanges.
Flexible IT solutions to address requirements with customizable functionality.
Functionality that adapts to meet the complexities and demands of the Medicare Advantage market.
Functionality that adapts to meet the complexities and demands of the Managed Medicaid market.
Flexible solutions to coordinate multiple compliance requirements and ease administration burdens.