TriZetto

The feature calculates a patient’s expected out-of-pocket responsibility before the service is delivered. It uses real-time eligibility and benefit information from the payer, including coverage status, co-pays, and deductible details, to determine what portion of the cost the patient may need to pay. It also generates a patient-facing estimate document that can be shared during the visit, allowing staff to discuss the expected amount and collect a deposit based on the estimated responsibility. By showing the expected balance earlier in the care process, Patient Responsibility Estimation helps practices address patient payments closer to the point of service.

TriZetto enables billing teams to submit authorization and referral requests electronically to payers through the HIPAA 278 transaction standard. It enables staff to create and send Health Care Services Review or Notice of Admission requests through the TriZetto portal, receive payer responses through the same channel, and track the status of submitted requests. The feature also supports admission certification, home healthcare authorization, specialty care referrals, and outpatient authorization requests. Users can also save incomplete requests for later completion and send certified payer responses directly from the portal. The software consolidates authorization requests and payer responses in one place, which could help practices reduce manual follow-up and better track approval timelines.

TriZetto lets practices manage patient balances after insurance processing by sending digital statements and giving patients online payment options. It sends billing notifications through text or email and supports Text-to-Pay, allowing patients to review balances and complete payments from their mobile device. Patients can save payment details for future transactions and set up payment plans based on the options configured by the practice. This gives practices an organized way to manage patient payments while allowing patients to handle balances through a digital payment process. It could also help practices collect patient balances earlier in the billing cycle by combining payment communication and collection in a single channel.

The software checks claims before submission and identifies those that may be rejected or denied by the payer. It combines claim scrubbing, eligibility verification, and machine learning-based denial prediction to review claims before they leave the provider’s system. The claim scrubbing process checks for coding-related issues, eligibility verification confirms coverage details, and the prediction model uses historical payer denial patterns to flag claims that may pass standard checks but still have a higher risk of rejection. Since TriZetto dentifies potential issues before submission, it could help billing teams reduce avoidable claim rework and address denial risks earlier in the revenue cycle.

Analytics tools analyze claim and payment data from the TriZetto clearinghouse account and present it through filterable dashboards and reports. Using these tools, users are able to review metrics such as claim acceptance, rejection reasons, payment activity, and processing timelines. They can also filter reports by payer, claim type, or reason code to identify the claims contributing to a trend. These tools support performance comparisons and benchmarking to help organizations evaluate revenue cycle patterns over time. They can give insights to revenue teams into where delays, denials, or payment issues are occurring, helping them determine where attention is needed.