<h5><b>Healthcare case study</b></h5>
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<h3 class="m-0 pb-1"><b>At a glance</b></h3>
<p><span class="text-accent1-light"><b>Industry<br> </b></span>Healthcare</p> <p><span class="text-accent1-light"><b>Challenge</b><br> </span><span style="line-height: 26.0px;">Migrate 300,000-plus senior market administration members to new core platform</span></p> <p><span class="text-accent1-light"><b>Products and services</b></span></p> <ul> <li>TriZetto Enrollment Administration Manager (EAM)</li> <li>TriZetto Facets core administration system</li> </ul>
<p><b><span class="text-accent1-light">Success Highlights</span></b></p> <ul> <li>85% enrollment first pass rate</li> <li>61% of DTRR fallouts corrected via automation</li> <li>100% elimination of duplicate CMS DTRRs</li> </ul>
<h3><span class="text-accent2-dark"><b>The approach</b></span></h3> <p>Blue Cross NC chose Cognizant’s TriZetto® Enrollment Administration Manager (EAM) and TriZetto® Facets® core administration platform as the foundation for consolidating onto a single technology ecosystem. The plan selected EAM and Facets for their proven industry record and frequent, feature-rich updates. With EAM and Facets, Blue Cross NC wanted to streamline the Medicare Advantage enrollment process, make member care more efficient and quickly adapt to industry trends with no fears about system limitations.</p>
<h5 class="text-accent2-light"><b>Executing a comprehensive plan for a complex migration</b></h5> <p>Working with Blue Cross NC teams, we carried out meticulous planning and developed new migration and implementation strategies, testing capabilities to ensure the transition to EAM and Facets went smoothly and met expectations for improved operations and member experience curated to the client’s specifications. </p> <p>The migration was complex. Our client had four unique plan contracts with the Centers for Medicare & Medicaid Services (CMS), with 13 plan benefit packages (PBPs) totaling 22 segmented plan offerings and 100-plus state county codes. The diverse contracts included Medicare Advantage only, Medicare Advantage Prescription Drug (MAPD) and Prescription Drug only plans. The possibility of members moving among these contracts further complicated the transition. </p>
<p class="pt-1">The initial migration would include approximately 157,000 existing Medicare Advantage members, plus an additional 25% net new membership expected during the AEP for plan year 2025. We would also be migrating about 150,000 Medicare supplement plan members. </p> <p>Experienced project management and seamless data migration and integration would be critical to avoid any service interruption to members and the business. Working with the Blue Cross NC operations team, we created a comprehensive schedule and checklist to follow during each environment build. This checklist helped mitigate installation challenges.</p> <p>We developed a Batch Beneficiary Eligibility Query (BEQ) and a Daily Transaction Reply Report (DTRR) tool. These macro-based file creation tools replicated CMS responses. Our teams used these extensively in development and testing phases before establishing connectivity with CMS. We also did extensive testing in lower environments around EAM and Facets basic configuration. We then tailored the baseline configuration by incorporating user feedback.</p> <h5 class="text-accent2-light"><b>Leveraging built-in EAM and Facets capabilities for seamless business continuity </b></h5> <p>Working together, Cognizant and Blue Cross NC teams took steps to ensure the migration to Facets and EAM would be transparent to members and seamless for operations. These included loading 36 months of membership history into EAM to support business continuity and manage retroactive enrollment changes. We also loaded catch-up data from legacy systems after the initial migration by using EAM’s electronic application file (EAF) TC00 and CMS DTRR.</p> <p>Member IDs and Rx IDs were seamlessly migrated from the legacy systems to EAM and Facets, with new ID cards and explanatory letters promptly created and sent so there was no impact on continuity of care. EAM and Facets enabled mass submission of the Rx ID changes to CMS by submitting TC72 files for the entire migrated membership.</p> <p>As a further safeguard to ensure all current and legacy data was captured, our joint teams performed dual maintenance between the legacy and new core systems for 18 months after the seamless transition to EAM and Facets. </p>
<h3><span style="font-weight: normal;"> <b><span class="text-primary">Business outcomes</span></b></span></h3> <p>In the first two years after migrating to EAM, Blue Cross NC achieved an excellent first pass rate of 85% while AEP enrollment activity approximately doubled, from 20,000 to 41,000. Audit reconciliation capability helps closely track contract enrollment application counts sent between CMS and EAM.</p> <p>Additional benefits include:</p> <ul> <li>62% reduction in pre-Facets fallouts for TC61 enrollment transactions in the Facets Enrollment Toolkit (FET)</li> <li>61% of DTRR fallouts corrected via EAM automation, and 100% of duplicate DTRR transactions sent by CMS were eliminated</li> <li>Billing accuracy improved with 100% updates to billing definition (BLDF) for any status change to premium withhold indicator in Facets</li> <li>Turnaround time for identifying valid primary care physicians plummeted from five to 15 minutes per member to just a few seconds</li> <li>Staff workload planning was optimized with EAM’s workflow aging notification reports</li> </ul>
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