Having mitigated downstream challenges for networks and other entities which performed re-pricing processes in-house, it became clear to REVELOHEALTH that re-pricing hadn’t been a core competency required for today’s healthcare landscape. This was more evident as payer contracts became increasingly complex, compounding errors, multiple re-pricing passes and costs. A group of accomplished leaders from all aspects of the healthcare ecosystem met this challenge head-on by creating REVELOHEALTH as a standalone entity to focus purely on claims re-pricing for third-party administrators (TPAs). While the company wanted to offer independent re-pricing services using raw claims data as the foundation for data analysis services, it was unable to find the right operating niche. Cognizant’s expertise in the industry led REVELOHEALTH to choose TriZetto® solutions as the foundational partner for its REPricity solution.
Cognizant worked with REVELOHEALTH to create its REPricity solution, which automates the entire re-pricing function in real time for TPAs and employer groups. Leveraging the TriZetto® QicLink™, TriZetto® ClaimsExchange™ and TriZetto® NetworX Pricer® implementations, REPricity has a fast, high-volume process that can re-price 93 claims in mere seconds.
QicLink stores all TPA data and provider demographics, including network associations, contracts and the rate sheet identification for each provider. TriZetto ClaimsExchange captures and submits ANSI 837 claims (HIPAA forms used by healthcare suppliers and professionals to transmit healthcare claims) to TriZetto NetworX Pricer. The solution also extracts provider network data and rate sheets from QicLink in real time. When a provider is matched to a network hierarchy, TriZetto ClaimsExchange routes the claim to TriZetto NetworX Pricer for re-pricing. Then, TriZetto ClaimsExchange picks up and submits the re-priced 837 claim to a TPA’s claims processor for adjudication. This process enables REPricity to re-price complex contract models and mine data to uncover how a specific health plan performs in different geographic regions or among different employee groups. The REPricity solution has also integrated a connection to Optum to capture formulary data consisting of lists of drugs that REPricity captures for the company’s payers.