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Case study

The challenge

Kern Health Systems (KHS), a managed care health plan headquartered in Bakersfield, California, serves recipients of Medi-Cal, California’s Medicaid program for low-income individuals in Kern County. During the pandemic, there was a rapid increase in Medi-Cal members as employees cycled off their company-sponsored healthcare and state eligibility guidelines relaxed. In addition to KHS’s growing claims volume, the plan needed to meet state regulatory requirements to develop alternative payment model (APM) programs in support of its Medi-Cal business. California regulatory mandates require KHS to create new provider contracts quickly. However, the plan’s growing number of claims led to more time-consuming manual work and the need for additional resources to handle the increased claims. To tackle these challenges, KHS needed a partner that was more than just a vendor, so the plan turned to Cognizant.

Our approach

We worked with KHS to update its automated processes and enable APM contracts, so that the plan could negotiate complex new APM contracts and convert existing fee-for-service contracts to alternative payment methods with accuracy and efficiency. The new capabilities use the TriZetto® NetworX Suite®, comprised of NetworX Pricer®, NetworX Modeler® and NetworX Modeler® Analytics. The solutions help KHS meet its business, technological and operational requirements and offer benefits such as real-time integration and alignment with core TriZetto® QNXT™ software, flexibility to support complex provider contract reimbursement types, increased auto-adjudication and automatic pricing. The implementation builds on a long-standing partnership with Cognizant, when KHS first became a TriZetto QNXT client and opted to help us enhance our NetworX solutions.

Helping KHS grow claims processing automation

Over the extended engagement, QNXT and the NetworX Suite have helped KHS grow claims processing automation, introduce new products and meet compliance requirements while maintaining the provider’s auto-adjudication goals—all without having to add additional staff. The TriZetto NetworX Suite helps KHS automate its APM processes, making it easier to manage contracts and view the financial implications of moving from a fee-for-service contract to an APM. By leveraging NetworX Suite, KHS has not had to increase its number of claims examiners or configuration team members. This adds efficiency and allows the provider to redirect staff to other operational and compliance-related priorities. KHS leverages the NetworX Suite to ensure timely provider reimbursements. The NetworX Suite also allows KHS to incorporate telehealth reimbursements quickly—within minutes for each contract.


overall auto-adjudication with QNXT and NetworX


overall automatic system pricing with NetworX


decrease in manually priced claims with NetworX