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The retail marketplace is about to intensify competition in the healthcare industry. With an estimated 30 million new members entering the market in the near future you will need sophisticated IT solutions which enable you to launch new lines of business quickly, automate processes, and improve efficiency in order to successfully manage the influx of members. Much of the anticipated growth will likely develop in the individual, family, small group and Medicaid markets. This means you will also need solutions that provide features consumers will demand, including web-based self-service capabilities for transactions, and online access to information about healthcare coverage and medical data. You will also need systems that enable you to receive and interpret transactions from multiple sales channels, including public and private health insurance exchanges and insurer-fielded portals for members/employers/brokers.—for example, reports about enrollments, diagnoses and life events.—
TriZetto’s solutions give you the tools you need to promote products to consumers. You can exchange data with members, employers, and providers in real-time, and compete to win in a rapidly changing business environment.
Whether you administer individual, family, small group or Medicaid lines of business, TriZetto's Facets® and QNXT™ platforms are the leading core administrative systems for payers serving these markets. Both Facets and QNXT automate business processes, enhance efficiency and provide the flexibility to administer diverse plan designs. TriZetto's solutions integrate with third-party solutions and adapt easily to a rapidly-changing business and regulatory environment.
Giving access to members, providers, employers and brokers alike to perform self-service inquiries and transactions is critical to driving convenience and satisfaction. Addressing the needs of these new healthcare consumers will require a set of tools that help provide the necessary information to these members when they need it, both efficiently and cost-effectively.
HHS has recently confirmed that the Edge Server requirement is not only for health plans that participate in Exchanges, but also for health plans that serve the individual and small group markets. Health plans need to be able to share consolidated, scrubbed and masked information that includes enrollment, medical claims, and pharmacy claims data on a recommended monthly basis.
Pre-integrated with TriZetto’s Facets™ and QNXT™ core administration applications, TriZetto Encounter Data Manager (EDM) for Exchanges provides an interface from the enrollment and claims data sources to generate and edit files submitted through the Edge Server to HHS. The EDM for Exchanges application helps you scrub, mask, submit and track complete files according to the varying HHS submission and format requirements for delivery to the Edge Server. The solution allows for greater efficiency and supports your compliance efforts with accurate submission files and error fixes to better maximize risk scores and deliver higher reinsurance revenue. EDM for Exchanges can run on premise at your facilities or you can opt to utilize TriZetto’s AMS services to host and support the solution. EDM for Exchanges can be used with other non-TriZetto core administrative platforms.
Discover the key steps to consider when making a decision to launch a payment bundling pilot program.
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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.