Cost Sharing Complex Example-02

Let us suppose typical terms and conditions of the plan are as follows:

Individual/Family Health Plan(INN & OON Providers)

Plan Year:1-1-2016 to 12-1-2016

Deductible:

INN Individual Deductible: $3000, INN Family Deductible: $6000

Per member INN provider deductible within a family: $6000

OON Individual Deductible: $6500, OON Family Deductible: $12000

Per member OON provider deductible within a family: $12000

Special condition1: If the contract has more than one member, Individual Deductible is not applicable, in this case only Family deductible will be applied. Plan will pay only when the total INN family deductible $6000 or OON family deductible $12000 is paid.

Special condition 2: INN provider deductible will NOT be counted towards OON provider deductible and OON provider deductible will NOT  be counted towards INN provider deductible.

Coinsurance:

In Network (INN) Providers Coinsurance: 70%-30%

Out Of Network(OON) Providers Coinsurance:60%- 40%

Out Of Pocket:

INN Individual Out Of Pocket : $6000, INN  Family Out Of Pocket: $12,000

OON Individual Out Of Pocket : $12500, OON  Family Out Of Pocket: $25000

Special condition 1: If the contract has more than one member, Individual Out Of Pocket is not applicable, in this case only Family Out Of Pocket will be applied. Plan will pay 100% benefits only when the total family Out Of Pocket limit(INN/OON) is paid.

Special condition 2: Deductible, coinsurance will be counted towards out-of-pocket amount. INN provider deductible and coinsurance will NOT be counter towards OON provider Out Of Pocket and OON provider deductible and coinsurance will NOT be counted towards INN provider Out Of Pocket amount.

Now let us suppose, the contract/ policy holder has following members: 

Member Number 1: Tiger Man- Subscriber

Member Number 2: Mrs. Tiger- Member

Member Number 3: Tiger Boy Member

Member Number 4: Tiger Girl- Member

Now let us calculate Cost Sharing for this contract of 4 members:

Step 1: 

Date of treatment: 1/15/2016

Patient: Member Number 1

Place of treatment: Inpatient Hospital 

Revenue codes: Use applicable codes per test case

CTP code: Use applicable codes per test case

ICD 10 diagnosis code: Use applicable code  per test case

Provider: INN provider (Hospital)

Allowable charge: $7000

Note: Though the individual deductible is $3000, yet as per terms and conditions of the plan, the $6000 will be accumulated to family deductible and 30% of $1000 will accumulate to Out Of Pocket amount. 70% of $1000 will be treated as benefits.

Total INN OOP=6300

Break-up:

 Deductible: $6000

+Coinsurance: $300 (30% of $1000)

Step 2: 

Date of treatment: 2/15/2016

Patient: Member Number 1

Place of treatment: Inpatient Hospital

CTP code: Use applicable codes per test case

Rev codes: Use applicable codes per test case

ICD10 diagnosis code: Use applicable code per test case

Provider: OON provider (Hospital)

Allowable charge: $14000.00

Note: Though the individual deductible is $6000, yet as per terms and conditions of the plan, the $12000 will be accumulated to family deductible and 40% of $2000 will accumulate to Out Of Pocket amount. 60% of $2000 will be treated as benefits.

Total OON OOP=$12800

Break-up:

 Deductible: $12000

+Coinsurance: $800 (40% of $2000)

Step 3: 

Date of treatment: 2/25/2016

Patient: Member Number 2

Place of treatment: Inpatient Hospital

Revenue codes: Use applicable codes per test case

CTP code: Use applicable codes per test case

ICD 10 diagnosis code: Use applicable code per test case

Provider: INN provider (Hospital)

Allowable charge: $19,000.00

Note: As family deductible limit $12,000.00 is met in step 1, no deductible will be applicable here. As coinsurance rate for INN provider is 60%- 40%, plan will pay $13,300 as benefit and plan holder will pay $5700 as coinsurance. In this stage, total INN family out of pocket amount will be $12,000.00 breakup is as follows:

From step 1: $6300.00

From step 3:$5700.00 

Step 4: 

Date of treatment: 3/30/2016

Patient: Member Number 2

Place of treatment: Inpatient Hospital

Revenue codes: Use applicable codes from per test case

ICD10 diagnosis code: Use applicable code per test case

CTP code: Use applicable codes per test case

Provider: OON provider (Hospital)

Allowable charge: $30,500.00

Note: As family deductible limit $12000.00 is met in step 2, no deductible will be applicable here. As coinsurance rate for OON provider is 60%- 40%, plan will pay $18,300.00 as benefit and plan holder will pay $12,200.00 as coinsurance. In this stage, total family out of pocket limit $25,000.00 will be met, breakup is as follows:

From step 2: $12,800.00

From step 4:$12,200.00

Step 5: 

Date of treatment: 4/30/2016

Patient: Member Number 3

Place of treatment: Doctor's office

CPT codes: Use applicable codes per test case

ICD 10 diagnosis code: Use applicable code per test case

Provider: INN provider (Cardiologist)

Allowable charge: $1000.00

Note: As INN Family out of pocket  limit $12,000.00 is met in step 2, the plan will pay 100% of the allowable. Subscriber/member will no more pay any treatment cost for  INN providers for the rest of the plan year.

Step 6: 

Date of treatment: 5/15/2016

Patient: Member Number 4

Place of treatment: Doctor's office

CPT codes: Use applicable codes per test case

ICD 10 diagnosis code: Use applicable code per test case

Provider: OON provider (Cardiologist)

Allowable charge: $2000.00

Note: As INN Family out of pocket  limit $12,000.00 is met in step 2 and OON Family out of pocket  limit $25,000.00 is met in step 4, the plan will pay 100% of the allowable. Subscriber/member will no more pay any treatment cost for the rest of the plan year, that is, up to December 31, 2016. So from now on,  no cost sharing will be applicable.

Cost Sharing Complex Example-01

Let us suppose typical terms and conditions of the plan are as follows:

Individual/Family Health Plan(INN & OON Providers)

Plan Year:1-1-2016 to 12-1-2016

Deductible:

Individual Deductible: $2000

Family Deductible: $4000

Special condition: If the contract has more than one member, Individual Deductible is not applicable, in this case only Family deductible will be applied. Plan will pay only when the total family deductible $4000 is paid.

Coinsurance:

In Network (INN) Providers Coinsurance: 80%-20%

Out Of Network(OON) Providers Coinsurance:60%- 40%

Out Of Pocket:

Individual Out Of Pocket : $4000

Family Out Of Pocket: $8000

Special condition 1: If the contract has more than one member, Individual Out Of Pocket is not applicable, in this case only Family Out Of Pocket will be applied. Plan will pay 100% benefits only when the total family Out Of Pocket $8000 is paid.

Special condition 2: Deductible, coinsurance will be counted towards out-of-pocket amount. INN provider deductible and coinsurance will also be counter towards OON providers Out Of Pocket and OON provider deductible and coinsurance will also be counted towards INN provider Out Of Pocket amount.

Now let us suppose, the contract/ policy holder has following member:

Member Number 1: Tiger Man- Subscriber

Member Number 2: Mrs. Tiger- Member

Member Number 3: Tiger Boy Member

Member Number 4: Tiger Girl- Member

Now let us calculate Cost Sharing for this contract of 4 members:

Step 1:

Date of treatment: 1/15/2016

Patient: Member Number 1

Place of treatment: Inpatient Hospital 

Revenue codes: Use applicable codes per test case

ICD 10 diagnosis code:Use applicable code  per test case

Provider: INN provider (Hospital)

Allowable charge: $3000

Note: Though the individual deductible is $2000, yet as per terms and condition of the plan, the entire $3000 will be accumulated to family deductible and Out Of Pocket.

Step 2:

Date of treatment: 1/30/2016

Patient: Member Number 2

Place of treatment: Inpatient Hospital

Rev codes: Use applicable codes per test case

ICD10 diagnosis code: Use applicable code per test case

Provider: OON provider (Hospital)

Allowable charge: $5000

Note: Here $1000 will be applied as deductible and then family deductible limit $4000 will be met. As on coinsurance rate for OON provider is 60%- 40%, plan will pay $2400 as benefit and plan holder will pay $1600 as coinsurance. Total family out of pocket amount will be $$5600, breakup is as follows:

From step 1: $3000

From step 2:$1000+$1600=$2600

Step 3:

Date of treatment: 2/15/2016

Patient: Member Number 3

Place of treatment: Inpatient Hospital

Revenue codes: Use applicable codes per test case

ICD 10 diagnosis code:Use applicable code per test case

Provider: INN provider (Hospital)

Allowable charge: $4000

Note: As family deductible limit $4000 is met in step 2, no deductible will be applicable here. As coinsurance rate for INN provider is 80%- 20%, plan will pay $3200 as benefit and plan holder will pay $800 as coinsurance. In this stage, total family out of pocket amount will be $6400, breakup is as follows:

From step 1: $3000

From step 2:$1000+$1600=$2600

From step 3:$800

Step 4:

Date of treatment: 3/15/2016

Patient: Member Number 4

Place of treatment: Inpatient Hospital

Revenue codes: Use applicable codes from per test case

ICD10 diagnosis code:Use applicable code per test case

Provider: OON provider (Hospital)

Allowable charge: 4000$

Note: As family deductible limit $4000 is met in step 2, no deductible will be applicable here. As coinsurance rate for OON provider is 60%- 40%, plan will pay $2400 as benefit and plan holder will pay $1600 as coinsurance. In this stage, total family out of pocket limit $8000 will be met, breakup is as follows:

From step 1: $3000

From step 2:$1000+$1600=$2600

From step 3:$800

From step 4:$1600

Step 5:

Date of treatment: 4/15/2016

Patient: Member Number 4

Place of treatment: Doctor's office

CPT codes: Use applicable codes per test case

ICD 10 diagnosis code:Use applicable code per test case

Provider: OON provider (Cardiologist)

Allowable charge: 1000$

Note: As out of pocket  limit $8000 is met in step 4, the plan will pay 100% of the allowable. Subscriber/member will no more pay any treatment cost for the rest of the plan year, that is, up to December 31, 2016. So from now on,  no cost sharing will be applicable.

Facets Criteria Maintenance application group

Utilization Management (UM) is a series of integrated processes that help to ensure that treatment is medically necessary as required by the member’s contract. The goal is to discourage or avoid medically unnecessary treatment. And at the same time it ensures that medically appropriate care is cost effective.  

"Clinical edits" indicates  the evaluation of billed codes in relationship to each other for the purpose of identifying unbundled procedures, surgical coding errors, invalid data relationships, patterns of utilization that deviate from practice standards, and diagnoses or procedures that may be invalid for the age and/or gender of the patient.

The Criteria Maintenance group consists of those applications that let healthcare payers set up the evaluation criteria that they need during utilization review, clinical editing, and capitation processing to make authorization decisions based on established medical criteria. This information helps claim reviewers or claims examiners to make authorization decisions based on established medical criteria. It can also help them to detect potential or actual billing issues with a provider’s claim. The group's applications are as follows:

1) AE Criteria by Diagnosis

2) AE Criteria by Procedure

3) Alternate Criteria Definition

4) Clinical Editing Criteria

5) Clinical Organ/Disease Panels

6) CPT to ICD  Conversion

7) CT/SC/DI Criteria

8) Dental Clinical Edit Criteria

9) Diagnosis Criteria M&R

10) Diagnosis Edit Criteria

11) Length of Stay by Diagnosis

12) Length of Stay by Procedure

13) Medical Admission Criteria

14) Optimal Recovery Guidelines

15) Procedure Criteria M&R

16) Procedure Edit Criteria

17) SameDay/Followup/PretreatProc

18) SSO Waiver Criteria

19) Surgical Admission Criteria

20) Surgical Indications M&R

Abbreviations:

AE stands for Adverse Event

M&R stands for Medicare and Retirement

SSO Waiver stands for Second surgical Opinion Waiver

TriZetto and its Payer Solutions-V

TriZetto's Payer Solutions cover the following areas:

1. Core Administration

2. Care Management

3. Health TranZform

4. Network Management

5. Value-Based Solutions

6. Portal Technology Solutions

7. Optimization Tools

So far we have discussed 1-6 areas. Now we will throw some light on TriZetto Optimization Tools suite.

7. TriZetto Optimization Tools suite

TriZetto Optimization Tools suite is designed specifically to automate operational tasks associated with TriZetto core healthcare technology solutions—tasks such as migrating and managing configurations, keeping security data synchronized among environments, and speeding the auto-enrollment process. The current tools of the suite are as follows:

i: Claim Test Pro™

ii: Configuration Maintenance Tool

iii: Configuration Migration Utility (for Facets™ & QNXT™)

iv: Facets Enrollment Toolkit

v: Test Data Generator for Facets™

vi: Security Management Tool

vii: Supplemental Mapping Management Tool for Facets™

7.i: Claim Test Pro

CLAIMS TESTING HAS NEVER BEEN SO ORGANIZED.

The TriZetto Claim Test Pro greatly reduces the need for manual creation of test cases, automates the management and reconciliation of results, tracks and documents test projects and cases, and electronically converts system data to applicable testing data sets to create a robust and applicable testing environment.

The Claim Test Pro application provides a comprehensive set of testing suites that provide for more diverse testing schemas, enabling testing of a multitude of provider reimbursement scenarios. The solution automates many processes that previously were done manually, helping plans increase administrative efficiency by reducing the resources needed to manage these initiatives. The Claim Test Pro solution  provides management tools that track and report progress.

What The Claim Test Pro can do for healthcare payers :

Ø  Reduce over payments to providers. Data that has been thoroughly vetted helps ensure that their plan is paying its contracted providers the correct amounts.

Ø  Reduce administrative costs. Reducing errors in provider payments reduces manual rework, helping drive down costs.

Ø  Reduce test cycle time. Automation can help them save hundreds of hours building and documenting test cases.

Ø  Reduce critical defects introduced to production. The application is virtually self-documenting, automatically summarizing what you have tested and reconciled.

7.ii:  Configuration Maintenance Tool

Change is a constant with which all health plans of Insurance companies must deal.  Changes may be the result of software implementations/upgrades, new lines of business, new products, acquisitions or expansions of member/provider groups, or improvements in administrative efficiency. So healthcare organizations configure these changes in their systems or tools. Any change in any place means configuration, so configuration is a continuous process. But is very vital to maintain and track configuration changes. TriZetto's Configuration Maintenance Tool can do a good job in this regard.

7.iii: Configuration Migration Utility (for Facets & QNXT)

The TriZetto Configuration Migration Utility helps healthcare payers to control and manage system configuration changes and successfully execute configuration promotions. Versions are available for both Facets and QNXT core administration systems. The Configuration Migration Utility gives non-healthcare IT personnel the ability to migrate specific aspects of configuration changes from environment to environment in a manner that is controlled, workflow-integrated and audit-capable.

With this tool, they can:

Ø  Eliminate wholesale environment copies. Perform targeted component migrations of desired configurations.

Ø  Reduce demands of specialty healthcare IT resources. Reduce the demands on database administrators during change promotions.

Ø  Ensure adherence to change procedures and approval processes. Enforce a rigorous workflow process while distributing the execution work efforts.

Ø  Reduce testing demands and rework. Test only the migrated component instead of re-executing wholesale test cycles.

7.iv: Facets Enrollment Toolkit

TriZetto’s Facets Enrollment Toolkit is a set of integrated tools and adapters that streamline the auto-enrollment process. The toolkit increases the auto-enrollment success rate by intelligently managing the data receipt and correction process for enrollment records that help healthcare payers  to be ensured that data is correct and validated before it is submitted to Facets. This significantly increases the number of records that will be accepted on first pass. For those records that require rework, the toolkit expedites the error identification process, so records can be corrected and resubmitted quickly. The Facets Enrollment Toolkit enhances healthcare payers'  confidence in automation routines by:

Ø  Reducing manual labor in enrollment-record processing. The toolkit reduces failure rates and, if failures do occur, improves time to resolution.

Ø  Increasing data accuracy and record-processing success. Front-end automation in the staging database helps ensure data is correct before it is inserted into the Facets system.

Ø  Decreasing demands on healthcare IT specialist during error-resolution cycles. The error record reader helps identify and resolve issues quickly.

Ø  Improving customer satisfaction. Data-management flexibility helps improve the intake process and expedite enrollment completion.

7.v: Test Data Generator for Facets

TriZetto Test Data Generator for Facets helps address the issue of exposing protected health information (PHI) when creating non-production data sets for use in testing with the TriZetto Facets core claims administration system.

This data copy tool allows for a subset selection of transaction data and masks key personal identifiable data. It permits a user to request a specific number of members from a production database, and acquire all the relevant groups, providers, and claims from the source database. The tool strips the data of personal identifying information and creates key word files with all new identity information. The result is size-controlled data sets of randomized non-production data. Using Test Data Generator for Facets, health plans can:

Ø  Reduce the risk of exposing PHI that occurs when production data is simply copied into non-production data bases for testing.

Ø  Allow for creation of multiple specialized test databases and control their size and composition.

Ø  Reduce non-targeted environment copies

Ø  Reduce demands on specialty IT resources

Ø  Improve security

7.vi: Security Management Tool

The TriZetto Security Management Tool provides an efficient way to configure, manage, import, troubleshoot and distribute Facets security configurations across multiple Facets environments. The solution provides a single, centralized repository of Facets security configuration data, with a user-friendly interface and full Facets integration that streamline the security configuration process. The tool provides a controlled, managed process for keeping configuration data in sync among environments such as training, development and production.

What TriZetto’s solution can  do for healthcare payers:

Ø  Reduce time required to configure Facets security profiles. New profile configurations can be completed in minutes instead of hours.

Ø  Streamline administrative tasks and reduce manual errors. Leverage the solution’s “compare and copy” features across environments to improve administration of profiles and access management.

Ø  Increase visibility into access-provisioning actions. Maintain a continuous log of security configuration changes. Create and customize audit-ready reports.

Ø  Provide audit-ready capabilities for their Facets security management. Ensure that their access-management process conforms to industry best-practices.

Ø  Implement a repeatable process.  Configure Facets security profiles once and then push them to multiple Facets environments.

7.vii:  Supplemental Mapping Management Tool for Facets

The Facets core administrative system from TriZetto and its optional modules provides payers the tools and resources to accommodate their business needs and new benefit plans. One of the ways the Facets solution accomplishes this is through the new supplemental mappings, which enable payers to have greater precision and more ways to configure the claims processing rules and qualifiers required by those new benefit plans.

The Supplemental Mapping Management Tool provides payer organization additional capability to manage new rules and qualifier groups, make configuration changes faster and more accurately, increase administrative efficiency, and optimize configurations for increased performance. With SMM, payer organization can:

Ø  Save hundreds of hours annually in configuration time by providing increased transparency of the current configuration and dependencies while streamlining configuration management tasks.

Ø  Improve configuration accuracy by reducing resource-intensive, error-prone manual editing, researching, and mapping of existing configurations.

Ø  Quickly edit, copy, or re-order rules that apply to specific criteria instead of scanning all rules individually.

Ø  Easily search the qualifier groups and rules within the Supplemental Mapping Management module with an easy to use interface.

TriZetto and its Payer Solutions-IV

TriZetto's Payer Solutions cover the following areas:

1. Core Administration

2. Care Management

3. Health TranZform

4. Network Management

5. Value-Based Solutions

6. Portal Technology Solutions

7. Optimization Tools

So far we have discussed 1-4 areas. Now we will throw some light on TriZetto Value-Based Solutions and Portal Technology Solutions .

5. Value-Based Solutions under Payer Solutions

Value-Based Solutions consist of Value-Based Benefits Solution and  NetworX Payment Bundling Administration.

5.i: Value-Based Benefits Solution

Value-Based Benefits Solution is a benefit design and incentive management software application that enables payers to customize benefits and other incentives for individual members based on health status, chronic conditions, or activities to  promote their health and wellness. his comprehensive automation solution enables payers to:

Ø  Design and manage member incentive programs using an easy-to-use graphic interface

Ø  Automate adjudication of value-based benefits at the member level

Ø  Automate enrollment, achievement and reward issuance, processing, and member incentive program communication

5.ii: NetworX Payment Bundling Administration

TriZetto NetworX Payment Bundling Administration provides a comprehensive software solution with patent-pending functionality that automates the prospective bundling process. Here’s how it works:

Ø  Integrates tightly with payers' claims processing system, whether that’s a TriZetto solution or third-party application.

Ø  Evaluates each fee-for-service claim made during the adjudication process to determine whether the claim belongs to an identified episode-of-care bundle.

Ø  Creates episodes of care prospectively, in real time.

Ø  Bundles related claims together from multiple clinicians working on a specific episode.

Ø  Re-prices claims to conform to the agreed total payment for each episode of care.

Part of the NetworX Suite of products for managing provider networks, TriZetto’s NetworX Payment Bundling Administration solution is available on a licensed or hosted basis to healthcare payers.

6. Portal Technology Solutions under Payer Solutions

Portal Technology Solutions consist of Member portal, Employer & Broker Solutions and Provider Solutions.

6.i: Member Portal

This portal consists of Member Service application, Treatment Cost Navigator solution and Member Benefit Profile

6.i(a): Member Service application

TriZetto’s Member Service application helps health plans meet the demand of members for high levels of client service while also helping to keep administrative costs low. Using the effective Web-based self-service tools that Member Service provides, health plan members can look up information and perform routine transactions at any time of day or night, from any location, without the help of a client service representative.

6.i(b):Treatment Cost Navigator solution

With self-service capabilities from TriZetto’s Treatment Cost Navigator solution, members can:

Ø  Estimate likely out-of-pocket costs for particular treatments.

Ø  Review eligibility for specific treatments.

Ø  Compare costs with accumulated deductible amounts and/or out-of-pocket maximums.

6.i(c): Member Benefit Profile

With TriZetto’s Member Benefit Profile™ application, insurance companies can give their health plan’s members an easy-to-read, well-organized and comprehensive view of their benefits, funds and healthcare utilization.

6.ii:  Employer & Broker

This portal consists of Employer & Broker Enrollment solution, Employer & Broker Bill solution and Employer & Broker Service solution

6.ii(a): Employer & Broker Enrollment solution

TriZetto’s Employer & Broker Service application provides easy-to-use self-service tools for employers and brokers who wish to perform transactions on behalf of members. The Service application not only can help payers improve satisfaction levels, but it also can help them reduce costly telephone calls and paper-based transactions.

6.ii(b): Employer & Broker Bill solution

The TriZetto Employer & Broker Enrollment solution enables employers and brokers to enroll new or open members, conduct all enrollment transactions, and send messages to members. Easy-to-use online tools guide users through enrollment transactions, increasing accuracy while helping you improve efficiency.

6.ii(c): Employer & Broker Service solution

With TriZetto’s Employer & Broker Bill solution, employers and brokers can view the bill, make roster adjustments based on a current invoice, view estimated impact of adjustments, and make a single payment or establish routine payments.

6.iii: Employer & Broker:

Provider  solution consists of Provider POS Direct solution and Provider Service application.

6.iii(a): Provider POS Direct solution

The TriZetto Provider POS Direct solution calculates patient financial liability and adjudicates claims at the point of service. With this valuable tool, providers can collect full payment at the time services are rendered—or, in some cases, even before the  patient’s visit—rather than days or weeks later. That means providers get immediate payment and members get no surprise costs.

6.iii(b):  Provider Service application

TriZetto’s Provider Service application enables providers to conduct a wide range of self-service transactions and inquiries in a secure online environment. For providers, that means getting faster and easier access to the information they need. For payers, it means increasing provider satisfaction, improving accuracy for higher first-pass rates, and reducing calls to payers' client service staff—all of which can help reduce cost and improve the quality of care.

TriZetto and its Payer Solutions-III

TriZetto's Payer Solutions cover the following areas:

1. Core Administration

2. Care Management

3. Health TranZform

4. Network Management

5. Value-Based Solutions

6. Portal Technology Solutions

7. Optimization Tools

So far we have discussed about Core Administration. Now we will throw some on Care Management,  Health TranZform and Network Management .

2. Care Management Under Payer Solutions

TriZetto's Care Management tool is CareAdvance Enterprise solution. It helps transform siloed care management into an advanced, member-focused, integrated program. Successful care management programs reduce costs, personalize interventions, enhance outcomes and improve the quality of care.  TriZetto’s CareAdvance Enterprise solutions can help healthcare payers meet the new challenges of care management. CareAdvance Enterprise comprises three solutions, including: TriZetto Clinical CareAdvance bringing automation to a wide range of clinical care management functions and TriZetto Personal CareAdvance, providing members with Web-enabled access to care information.

i. Clinical CareAdvance

Using configurable business rules, Clinical CareAdvance helps insurance organizations reduce cost and improve care management by providing personalized information and services and streamlining utilization management workflows. The solution also provides access to evidence-based clinical guidelines, improves data management, and provides tools that deliver significant benefits in disease management, case management solutions, and utilization management.

ii. Personal CareAdvance

The TriZetto Personal CareAdvance application gives healthcare payers a secure, web-based solution. It helps their members to manage their own health more effectively. Drawing from the Healthwise Knowledgebase, the Personal CareAdvance application proactively pushes appropriate information to the right person at the right time. The members get a 360-degree view of their personal health summary. The solution helps them:

Ø  To collect and record personal health information and complete and submit health risk assessments.

Ø  To track clinical metrics, receive reports on their health progress and receive alerts when their health status changes.

Ø  To interact with care managers, providers and family members.

In addition to providing a core health record and messaging platform, the Personal CareAdvance application delivers a wide array of integrated member health tools, including health diaries, medication and condition lists, a personal health summary, and more.

3. Health TranZform under Payer Solutions

Health TranZform is a new suite of solutions that enables collaboration across healthcare and breaks down data silos.The engine behind TranZform that enables healthcare stakeholders to easily interact across the care continuum is the TranZform Platform. The TranZform Platform enables cross-system communications, data reconciliation and interoperability to support healthcare transactions and decision-making.

i) EngageConsumer

EngageConsumer solution helps healthcare payers offer a competitive digital experience to attract new customers, retain current business, and compete in exchange markets. Mobile-enabled, portal-based, and flexible, the EngageConsumer solution provides functionality to help consumers easily shop for benefits, get quotes, compare plans, and enroll in a health plan through public or private exchanges.

4. Network Management under Payer Solutions

i) NetworX Modeler

ii)NetworX Pricer

iii)NetworX Payment Bundling Administration

i) NetworX Modeler

NetworX Modeler is a sophisticated contract modeling application that enables healthcare payers' contract management teams to perform in-depth, high-precision analyses of all provider contract scenarios. Healthcare payers can download actual historical claims data and run different scenarios at the contract-term level— no matter how complex the rates and terms. With this information, they can quickly forecast results, negotiate the best terms and improve the financial outcomes of every contract. All this can be done without the need of support from IT or other departments.

ii) NetworX Pricer

NetworX Priceris a Java-based application that integrates with TriZetto and non-TriZetto core claims administration systems. The NetworX Pricer application automates claims pricing for even the most complex provider contracts. With this patented and patent-

pending application, Healthcare payers can manage more sophisticated contracts easily, process claims faster, minimize inconsistencies  and reduce errors

iii) NetworX Payment Bundling Administration

This is how NetworX Payment Bundling Administration works:

Ø  Integrates tightly with payers' claims processing system, whether that’s a TriZetto solution or third-party application.

Ø  Evaluates each fee-for-service claim made during the adjudication process to determine whether the claim belongs to an identified episode-of-care bundle.

Ø  Creates episodes of care prospectively, in real time.

Ø  Bundles related claims together from multiple clinicians working on a specific episode.

Ø  Re-prices claims to conform to the agreed total payment for each episode of care.