Skip to main content Skip to footer
Case study

The challenge

Our client, Priority Health, has a complex quality management and reporting landscape that was challenging its ability to develop and submit comprehensive, accurate and timely reports required to achieve high ratings from the Centers for Medicare & Medicaid Services (CMS). The organization’s quality improvement and reporting workflows draw on more than 50 sources to compile the data necessary to achieve high Medicare Star and National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) ratings. The client needed a robust data integration and normalization engine that could provide a unified view of its member population and generate member insights using the data from all these sources.

Our approach

Priority Health selected Cognizant’s TriZetto® ClaimSphere® suite, a complete hosted quality and Star rating improvement solution that includes regulatory reporting services. ClaimSphere enables our client to gather and submit retrospective data for the NCQA’s HEDIS program. 

Our client was one of the first health plans to tap into the Michigan Health Information Network (MiHIN) as a source of supplemental data for HEDIS measures. Our teams worked closely together to develop interfaces with MiHIN that made it easier for providers and Priority Health’s plans to exchange data. We also helped the company streamline its medical record review validation process—a critical step in preparing for HEDIS audits—by developing a medical record abstraction function called Clinical+ Chart Abstractor. This tool makes it possible to convert data from a PDF and a variety of other formats into digital, searchable records to support quality reporting.

Related case studies

TriZetto ClaimSphere suite improves CMS Star rating

Accurate, on-time NCQA HEDIS reporting through Cognizant’s TriZetto ClaimSphere suite has helped Priority Health consistently increase its overall CMS Star rating. It increased from 4 to 4.5 Stars and then to 5 Stars, which resulted in increased bonus payments. In addition, most of the company’s clinical and pharmacy Star measures for Medicare perform above national benchmarks and NCQA gave a “commendable” accreditation status to the company’s Medicare, Medicaid and commercial contracts.


abstraction completed for 18,000+ active chases during first year of roll-out


abstraction completed for 22,529 chases during next HEDIS regulatory submission


Medical Record Review Validation audit score achieved


uptime, security and plan reliability for stakeholders achieved through Cognizant Hosting services