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TriZetto Healthcare Solutions / Government Solutions

TriZetto government solutions

We have the solutions you need to extend the functionality of your core system, fully integrated and immediately effective.

Meeting the complex data processing and compliance requirements of Medicare Advantage, managed Medicaid and Commercial Exchanges in a timely manner is critical to your success. Our TriZetto Elements® suite extends the functionality of your core system with the features you need. By providing critical capabilities for tasks ranging from enrollment through risk adjustment, Elements helps you efficiently drive these lines of business forward.

Our standalone solutions, including Facets®, QNXT™ and other core systems, integrate well together. The Elements products make it easy to share information and speed processing.

With Elements you can:

  • Track and transform encounter data.
  • Automate encounter, Risk Adjustment Processing System (RAPS) and risk adjustment data submission.
  • Facilitate interactions between your plan and Centers for Medicare and Medicaid Services (CMS).
  • Maximize reimbursements.
  • Accelerate response to regulatory changes.
  • Improve acceptance rates.
  • Reduce the risk of potential CMS penalties.

BEQ: The Batch Eligibility Query file includes transactions submitted by plans requesting eligibility information for prospective plan enrollees. Plans use BEQ files to conduct initial eligibility checks against the Centers for Medicare and Medicaid Services (CMS) Medicare Advantage Prescription Drug (MARx) database system to verify members Part A/B eligibility.

TRR: The Transaction Reply Report is a daily electronic CMS file that includes member information and updates. The files also include Transaction Reply Codes (TRCs) to explain the system’s actions in response to new information from CMS or input from managed care organizations (MCOs), CMS or other vendors.

OEC: Online Enrollment Centers submit Medicare membership information electronically. An Enrollment Administration Manager accepts these electronic enrollment files and automatically updates the membership.

LEP: Late Enrollment Penalty information is included in the daily CMS TRR files. Correct LEP information is attached to the member’s record and incorporated in the member’s premium billing statement.

MMR: The Monthly Membership Report is the electronic payment file from CMS. It is loaded automatically to help plans easily identify payment discrepancies and prioritize research for resolution.

HCC: CMS uses a Hierarchical Condition Categories model to adjust capitation payments to health plans for the health expenditure risk of their enrollees. The CMS Risk Adjustment Model measures the disease burden using diagnosis codes associated with more than 70 HCC categories. The CMS model is cumulative, meaning that over time patients can have more than one HCC category assigned to them. Some categories override others within the category hierarchy.

HCC MOR: The HCC Model Output Report file contains a series of flags indicating which demographic factors (age, sex and entitlements for Medicaid and disability) and disease factors (HCCs and disease interactions) are used to calculate the risk score for each beneficiary enrolled in the plan. Plans receive separate MOR files for Part C (CMS-HCC) and Part D (RxHCC) risk adjustment models.

Risk Adjustment: CMS uses risk adjustment to pay plans based on the risk of the beneficiaries they enroll, instead of using an average amount for all Medicare beneficiaries. By risk adjusting plan payments, CMS makes appropriate and accurate payments for enrollees with different cost expectations. Bids and payments are made based on the health status and demographic characteristics of an enrollee. Risk scores measure an individual beneficiary’s relative risk and are used to adjust payments for each beneficiary’s expected expenditures. By risk adjusting plan bids, CMS is able to use standardized bids as base payments to plans. Claims data is sent to CMS via:

  • RAPS: Risk Adjustment Processing System
  • EDPS: Encounter Data Processing System 
  • DDPS: Drug Data Processing System

TriZetto elements

Automated member eligibility verification directly with CMS (BEQ)

Accepts electronic enrollments, auto-enrollments and CMS OEC

TRR Rules Engine provides configurable rule-based processing of the daily TRR file plans received from CMS

Out of area verification process

Triggers Medicare correspondence and provides standard reports, including CMS compliance reports

Workflow tool automates the routing and assignment of work items based on specific roles, queues and priorities

One system for Medicare Part C and Part D payment reconciliation

Compares plan and CMS membership data to calculate payment and flag discrepancies

Prioritizes discrepancies with the most financial impact and provides actuaries/underwriting with key reports and data

Assist management with work assignment, workflow management and discrepancy aging

Ensures that your organization has the necessary tools to remain in full compliance with everchanging CMS regulations for financial reporting

Performs presubmission edits, including RAPS format conversions, to improve CMS acceptance and creates batch files for Palmetto (CSSC)

Loads and reconciles RAPS Reply files against plan-submitted claims and provides online editing capabilities for claims that plans can resubmit

Displays status history screen and reports to show progress of encounters through the entire process

Generates summary and detailed status reports for tracking

Automated workflow functionality

Integrates with the Enrollment Administration Manager and Financial Reconciliation Manager for accurate error resolution to delete incorrect diagnosis codes

Logic uses type of bill, revenue codes, place of service, procedure codes and combinations of these to determine services not submittable for risk adjustment

Provides a method of extracting paid claim data from your core claim systems, including ancillary data (for example dental, pharmacy, vision)

Manages the Encounter submission and response file process and holds claims that would normally be rejected so the issue can be resolved

Includes preconfigured Scrub and Business Rules and gives users the ability to create user-defined Scrus and Business Rules through an integrated toolkit

Speeds new market implementations using preconfigured market essential packages

Optional EDI Validator validates WEDI SNIP levels 1-7 utilizing TIBCO Instream

Encounter Data Manager includes an Online Provider Editing tool to edit encounter provider and member data at a claim or batch level within the application

Extensive standard reporting, dynamic dashboard and access the database for unlimited adhoc reporting

Identifies member HCCs and RxHCCs by payment year and data collection period based on a plan’s accepted RAPS and EDPS data

Compares plan HCC Information to CMS information on a member and payment year basis to identify discrepancies

Calculates plan Part C and Part D risk scores using plan and CMS demographic and HCC data

Identifies claim/diagnosis level RAPS and EDPS data in cases where CMS is missing accepted HCCs/RxHCCs that can be exported from risk score manager.

Provides detailed risk score and HCC related management reports and a dashboard

Reconciles submitted RAPS and EDPS data

Helps plans prioritize charts for review

Captures chart review results and provides actionable information on why a chart was selected

Tracks the impact of chart audit results on both Part C and Part D risk scores

Provides customizable reports to track financial impact of chart review audits

Generates files for submission of data to CMS

Provides a prospective evaluation tool that conducts user-defined assessments on members by evaluating their health prior to claims submission

risk adjustment management for exchange

Aggregates patient data (claims, pharmacy and demographics)

Works with Milliman Inc.’s IMPROVE product to generate clinical suspects from the compiled data in RAMX

Via an automated integration, RAMX consumes the clinical suspects for chart review and generates a list of supplemental diagnosis codes identified during the chart review process

Provides a Physician Inquiry Report (PIR) by member or by PCP that lists all previously identified HCCs and suspected HCCs generated through RAMX and IMPROVE use

Presents potential HCC data on the Manage Suspect screen for coders to utilize while entering data resulting from the chart review process

pde data manager sample

Loads prescription drug event files (DDPS replies only) and prescreens records for format and content per CMS edit criteria

Generates CMS PDE file format for records to be submitted, and tracks and appropriately updates adjustment and deletion records for resubmission

Imports CMS's return files and DDPS Reply files from PDE submissions, and updates record status and error codes

Allows users to edit and resubmit records from within the application

Provides P2P reconciliation and workflow

Provides and manages reports by file, batch, status, error code, PBP, etc.

Integrates with Enrollment Administration Manager and Financial Reconciliation Manager to accurately resolve eligibility and low-income cost sharing errors

Rx reconciliation manager

Calculates and reports on each of the Medicare Part D retrospective reconciliation measures: low-income cost sharing subsidy, reinsurance subsidy payment and risk corridor

Harnesses the data processing and tracking capabilities of FRM for prospective revenue reconciliation and PDE Data Manager for PDE data processing, submission and management

Analytical reporting reconciles Part D revenue using PDE and member data, as well as the impact of accepted and rejected PDE data

Encounter data manager for edge server

Comes pre-integrated with Cognizant's TriZetto Facets® & QNXT™ core administration applications

Provides an interface from the enrollment and claims data sources to generate and edit files submitted through the CMS EDGE Server to the Department of Health and Human Services (HHS)

Assists with scrubbing, masking, submitting and tracking complete files according to the varying HHS submission and format requirements for delivery to the EDGE Server

Increases efficiency and supports compliance efforts with accurate submission files and error fixes to better maximize risk scores and deliver higher reinsurance revenue

Includes a full suite of required risk adjustment and reinsurance reports

Claimshphere hedis sample

NCQA Certified HEDIS engine for retrospective regulatory reporting

Provides self-service BI for prospective gaps in care identification with faster turnaround time

Supports administrative HEDIS reporting for both NCQA HEDIS and HEDIS-like state measures and also supports state-specific measures

Built-in automated workflow management tool, Cockpit4DIA, ensures accurate and on-time submissions

Supports/integrates with all major data sources for administrative and supplemental data and facilitates MRR data integration

Starserv sample

End-to-end Medicare Star Rating assessment and improvement platform for CMS 5 Star Program for Medicare Advantage plans

Data-driven decision levers objectively prioritize measures and population cohorts that can improve overall Star Rating

Actionable business insights to improve Star Rating scores through prospective gaps in care reports and member prioritization algorithms for focused outreach

Responsive and easy-to-use interface with role-based dashboards and contextbased drill down to member-specific actionable data

Drives collaboration and accountability, derives actionable insights and facilitates continuous quality improvement