With QicLink™ and its component modules, you can administer a variety of plans in addition to medical, including PPO, HMO, Medicare Supplement, consumer-directed healthcare (CDH) and multi-option point-of-service plans, as well as plans with unique designs. The QicLink application supports these various lines of business with the following component modules.
This module auto-adjudicates claim/encounter data based on the dental-procedure. It accepts claim data electronically from remote locations and/or via OCR input from high-speed data entry. It modifies payment parameters based on provider-specialty codes, automatically replaces obsolete procedure codes, and performs procedure edits. It stores enrollee dental history and generates pre-authorizations, including pre-treatment payment estimates.
This module allows you to develop your own dental claims processing rules. The QicLink application uses these rules to electronically process dental claims based on criteria established for a specific plan, revision level, procedure, tooth surface, and age. The user-defined rules give your organization greater control over plan administration while helping ensure that the services provided meet the standard policy for the procedure code and the prior claim history.
This module enables you to easily set up and maintain calculation parameters for short- and long-term disability benefits. This includes specifying a benefit plan, establishing claim and payment generation, and processing year-end W-2 information. The system stores information for each employer group by effective date, check group, carrier, policy number, fund-account number, and minimum fund balance. Also, each group can be maintained using Federal, Medicare, Social Security, State, and two user-defined withhold tax tables.
The HMO module simplifies complex HMO plan administration. You can capture encounter information per member, per month utilization by specialty, by primary care physician (PCP), by procedure performed, and by procedure category. You can sort information by HMO, group, and reporting ID. The module also supports multiple direct-capitation relationships such as member to provider, as well as indirect capitation relationships, including PCP to member, or all members to a lab.
The PPO module lets users efficiently re-price negotiated benefits to contracted providers. It offers all the administrative functions you need to process PPO benefits, and reports, and to track discount information. You can establish point-of-service plans as well as unique contracting arrangements on a provider-by-provider basis, or on a provider-to-many-master basis. You can also set up a variety of flexible options for providers and their rates.
The TriZetto ClaimsExchange service seamlessly connects benefits administrators to a vast network of PPOs—routing claims and re-pricing data electronically through a single point of connectivity. The ClaimsExchange service automates and simplifies the re-pricing process, minimizing paperwork, manual intervention, and human errors. The result is a dramatic increase in auto-adjudication rates as well as significantly reduced administrative costs. Additional capabilities provide an automated solution for obtaining discounts on out-of-network claims via a post-adjudication electronic interface with fee negotiators that further reduces adjustments due to ineligible claims.
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TriZetto is a leading provider of healthcare technology for payers and providers. TriZetto facilitates integrated healthcare management with comprehensive solutions for core administration, health insurance claims processing, care management, IT hosting services, Medicare solutions and more. TriZetto’s innovative claims processing software streamlines claims administration to reduce costs and improve revenue cycle management.