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TriZetto FACETS Practice

Overcome the challenges posed by ever-changing compliance mandates and customer expectations while boosting your ROI through seamless FACETS implementations

Reinvented IT Infrastructure & Customized Core Application

Enabled business to identify and use the golden records from EDW data and consume it in downstream system

Batch Admin Support for an Insurance Provider

Optimization of long running jobs and parallel processing mechanism increased efficiency

ACS FACETS Platform Offerings

Our TriZetto FACETS practice helps in implementing and managing the FACETS platform to reduce plan administrative costs, improve business processes and deliver better value for care management solutions. In addition, our deep domain capabilities in healthcare will help you in managing the platform to manage your compliance needs like ICD-10, CMS, ITS, FSA carryover etc.We have deep expertise across all the modules of FACETS healthcare application. We have integrated the platform with other systems in the client application landscape. We have developed automation and analytics capabilities around FACETS systems to help you in your digital transformation journey and be future ready. Simultaneously, we offer cost effective managed services on the TriZetto FACETS platform to take care of day-to-day administrative tasks.

Examples of Our Expertise on FACETS platform

Enrollment

  • Performed member assessments, enrollments, health homes billing for Medicaid Health and recovery plan
  • Automated member eligibility rules for Medicare Special Needs Plan (SNP) and Medicaid Health and Recovery plan
  • Identified all Medicare SNP members who had 90-days assessments and 365-days reassessments
  • Extracted Member eligibility information from FACETS and generated enrollment files in HIPAA 5010 EDI 834 for Medical, Dental and Vision vendors
Hybrid Cloud Delivery
Managed IT Services

Billing and Payments Reconciliation

  • Integrated client’s systems with third party payment system which allows members to set-up recurring payments and make premium payments online seamlessly from member portal
  • Processed all premium bills to third party payment gateway to accept and process payments to member accounts
  • Reconciled member actual deposits from the exchange which includes subsidies for Advanced Premium Tax Credits (APTC) and Cost Sharing Reduction (CSR) against HIPAA EDI 820 policy-based payment notifications

Claims & Encounters

  • Validated and auto adjudicated Professional (837P), Institutional (837I), Dental (837D) and Pharma (NCPDP) claims from various provider networks / vendors and processed response in HIPAA EDI 277/835 form
  • Integrated Clients systems with third party vendor to process EDI 278 pre-authorization requests from providers in real time
  • Extracted and submitted all post adjudicated Medicaid claims (Medical 298P/299I, Dental 300D, Vision and Pharmacy NCPDP) State’s All Payer Database and improved state acceptance rate by fixing state exceptions – these will be used to calculate capitation rate and to identify the clinical areas for improvement
  • Reconciled encounters submissions against state responses and generated discrepancy report
  • Processed Medicare Advantage members post adjudicated claims data to CMS Risk Adjustment Processing System (RAPS) and CMS Encounter Data Processing System (EDPS) for risk score calculation
  • Collected member information from Charge sheets (part of Medicare charge sheet review) and validated against Clients FACETS system to process linked and unlinked claims accurately
  • Extracted commercial plans claim information and processed to EDGE server for Risk Score and Reinsurance calculation
Hybrid Cloud Delivery
Managed IT Services

Risk Adjustment

  • Helped in Risk Adjustment initiatives by analyzing the encounters and extracting data for chart review
  • Performed data aggregation, validation to obtain the suspect list and created reports to analyze the priority of suspect
  • Created workflow for analyzing the supplemental codes and submitted to State, CMS and EDGE as per the respective encounter information
  • Analyzed the response from government bodies and cleared out the errors in the submitted claims to achieve more than 99% accuracy in submission

Analytics

  • Processed member enrollment and claims data to third party system to calculate HEDIS measures for QARR reporting and STAR Rating
  • Created system to send demographic and claims data for 3M CRG to measure the risk associated to each member to predict future health care utilization and cost (prospective) and explain past health care utilization and cost (retrospective)
  • Analyzed and created HCC gap analysis to determine the members with chronic conditions and need provider’s attention
  • Created member 360 dashboard that can help the business users to understand the complete health profile of members and focus on people with chronic illness
  • Created analytical platform for customer care representatives for tracking the real time member information and provide services to members efficiently
  • Created vendor data marts to perform quick analytics on top of huge claims data related to various vendors
Hybrid Cloud Delivery
Managed IT Services

Automation Testing

  • Regression Testing – automation of FACETS batch jobs
  • Performance Testing – batch jobs testing and load testing
  • Reusability of test data, case and scripts
  • Collected member information from Charge sheets (part of Medicare charge sheet review) and auto validation against FACETS system to process linked and unlinked claims accurately

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