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HEALTHCARE

REVELOHEALTH automates real-time re-pricing with TriZetto


The challenge

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.


Our approach

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.

Delivering a fast, high-volume re-pricing service with TriZetto solutions

The REPricity solution’s unique service decouples re-pricing from the adjudication process to deliver insightful and actionable data from raw, unedited claims. With REPricity, the company can overcome data vulnerabilities with sophisticated provider and member matching. In addition, TriZetto NetworX Pricer allows the company to accommodate sophisticated re-pricing calculations and update fee schedules faster and easier, using global rate sheets. Our hosting support offers the company a way to interface with Optum—a component of another re-pricer mechanism through TriZetto NetworX Pricer—widening its ability to compare claims data. With our TriZetto solutions, the REPricity tool automates the entire re-pricing process so it can intake claims information and re-price claims multiple times, if necessary.

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97%

participating provider (PAR) claims matching achieved

98%

first pass accuracy in improving claims re-pricing outcomes

~100%

automation achieved, eliminating errors & cost from manual intervention

24/7 access

to insightful, actionable data from raw, unedited claims


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