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Maximize your government business potential
From enrollment through encounter submissions, augment your core administration system with features to automate processing.
Elements product suite
TriZetto® Enrollment Administration Manager (EAM), powered by TriZetto® Enrollment Administration Manager Workflow, helps health plans move from enrollment to acceptance. EAM streamlines the process to enroll your members in Medicare Advantage. The product is constantly updated to reflect CMS regulatory changes and can pass data to both the Facets® and QNXT™ platforms, making it a critical part of a complete solution. The workflow manages the overall enrollment process, improving visibility and tracking throughout the enrollment lifecycle.
TriZetto Enrollment Administration Manager and TriZetto Enrollment Administration Manager Workflow enable you to:
- Initiate enrollment changes, PBP changes, and other member changes from multiple channels including batch, web service and user entry.
- Leverage comprehensive validations of enrollment and member change transactions, streamlining enrollment processes to maximize acceptance rates and minimize unnecessary manual work.
- Automate member eligibility verification and related member correspondence directly with CMS Real-Time API or Batch Eligibility Query (BEQ).
- Automate OEC election retrieval, processing and reconciliation with CMS Real-Time API.
- Comply with Part C and Part D enrollment reporting requirements.
- Enable the robust processing of daily and special Transaction Reply Reports (TRR) when applying member updates and auto-triggering member correspondence.
- Enforce enrollment related CARA Legislation.
- Gain a clear view of daily enrollment work in progress.
- Enable and maintain compliance with CMS regulations.
- Automate the routing and assignment of work items based on specific roles, queues and priorities for issue enrollment and resolution.
- Integrate enrollment data with QNXT, Facets or other third-party core administration applications for billing, claims processing and member services.
TriZetto® Financial Reconciliation Manager (FRM) streamlines and automates the process of reconciling the amount plans have been paid by CMS with the member payments received, comparing plan and CMS membership data to flag and determine the impact of discrepancies. The system prioritizes inconsistencies with the greatest financial impact and provides key data to resolve discrepancies quickly.
With Financial Reconciliation Manager you can:
- Use one system for Medicare Part C and Part D payment reconciliation by member or Plan/PBP.
- Identify eligibility, member demographic, special status, low income, out of area and payment discrepancies.
- Correct your plan’s internal data system and submit corrections to CMS via the Retroactive Processing Center.
- Assist the management of work assignments, workflow management and discrepancy aging.
- Ensure that your organization has the tools to remain in compliance with CMS regulations for financial reporting.
TriZetto® Encounter Data Manager™ (EDM) and TriZetto Encounter Data Manager Workflow supports submission requirements and provides functionality to help our clients meet applicable compliance expectations, improve revenue and reduce overhead. EDM provides a configurable and scalable encounter management solution that produces agency compliant encounter transactions, while enforcing submission rules to help prevent non-compliant transactions from being submitted to CMS, Commercial Exchange or state agencies.
TriZetto Encounter Data Manager Workflow provides automation capabilities, improved visibility and efficiency to the encounter error correction process in order to enhance the completeness, accuracy and timeliness of the encounter submission.
- Reduce costs associated with inaccurate or incomplete data by providing quick and timely resolution of submission errors.
- Capture accurate data from multiple sources.
- Gauge potential financial mismatches and potential loss of revenue from CMS, Commercial Exchange or state agencies.
- Reduce total cost of ownership by replacing manual processes with automated workflow capabilities.
- Increase transparency, efficiency and control over error resolution through continuous monitoring capabilities.
- Improve compliance adherence and timeliness.
- Potential for risk score and revenue optimization by increased acceptance rate of encounters.
- Reduce the need for complex customization and state-specific solutions with built-in client configuration.
TriZetto® Risk Score Manager (RSM) analyzes data submitted by Claims Data Manager and Encounter Data Manager to calculate the risk scores your health plan can expect to be reimbursed based on the diagnoses submitted to CMS. It reconciles scores against monthly CMS data from the RAPS response files. With RSM, your health plan gains visibility into risk scores, which allows you to better forecast payments from CMS. RSM reconciles EDPS submissions to ensure the data submitted to CMS is accurate for both.
With Risk Score Manager you can:
- Identify member Hierarchical Condition Category (HCC) and Rx HCC by payment year and data collection.
- Compare HCC information to CMS information to identify discrepancies.
- Calculate Part C and Part D risk scores using plan, CMS demographics and HCC data.
- Provide detailed risk score and HCC-related management reports.
