Last Updated
Overview
TriZetto helps healthcare providers streamline claims management, patient engagement, and revenue cycle operations. While reporting customization is limited, its automated workflows enhance operational efficiency and reduce administrative burdens. It is suitable for hospitals, physician practices, and billing services seeking scalable healthcare management solutions.
TriZetto Specifications
- Billing and Invoicing
- Claims Management
- Appointment Management/Scheduling
- e-Prescriptions
What Is TriZetto?
TriZetto Provider Solutions is an RCM and clearinghouse platform focused on healthcare billing operations. It enables practices, hospitals, and billing organizations to submit claims, check them against payer requirements, process remittances, verify eligibility, estimate patient responsibility, and manage other revenue cycle functions. The software brings payer interactions and revenue cycle services together, allowing organizations to identify claim issues earlier, address reimbursement delays, and gain clearer insight into revenue performance.
Its broader offering also includes outsourced billing, coding, revenue recovery, and credentialing services. This lets organizations choose which revenue cycle functions to manage internally and which to outsource to TriZetto, based on their staffing capacity and operational needs.
What Is TriZetto Best For?
It stands out with TriZetto® Advanced Claim Editing, its pre-submission claim review feature. It combines automated eligibility checks, over 30,000 coding-specific edits, and uses AI and machine learning-based denial prediction to identify claims that may be rejected before reaching the payer. When an issue is flagged, users can review the reason and make corrections before submitting the claim.
Identifying coding and potential denial issues earlier in the submission process can help revenue cycle teams reduce avoidable rework and address reimbursement delays before they affect payment timelines. The predictive layer also uses historical claim data to surface denial patterns that fixed coding rules may miss, giving teams another way to understand changing payer requirements.
How Much Does TriZetto Cost?
TriZetto starting price is estimated at $300/month.
In addition to the base subscription costs, organizations should account for the following additional expenses:
- Setup And Implementation: $10,000–$100,000+
- Data Migration And Software Configuration: $5,000–$50,000
- User Training: $2,000–$20,000
- Maintenance And Support: 15–20% of annual license fees
Disclaimer: Pricing references are based on publicly available third-party information and industry benchmarks. Actual costs may vary.
TriZetto Integrations
The software supports integrations with various practice management systems and EMR solutions, such as:
How Does TriZetto Work?
Here’s a walkthrough of the software and how you can navigate its functionalities:
- Log in to your account through the portal assigned to your organization
- Check eligibility to confirm the patient’s coverage and benefits before the visit
- Estimate responsibility to determine the patient’s expected share of the bill
- Send claims from your practice management or EHR system into TriZetto
- Review flagged claims from Advanced Claim Editing and correct potential issues before submission
- Track claim status in the account as payers return updates
- Post payments from electronic remittance information or converted paper EOBs (Explanation of Benefits)
- Work denied claims by reviewing the payer’s reason, correcting the claim, and filing an appeal where needed
- Analyze claim trends to review recurring denial patterns by payer and reason
Who Is TriZetto For?
TriZetto is designed for the healthcare sector and is commonly used by:
- Health systems
- Hospitals
- Billing services
- Physician practices
- Payers
TriZetto Use Cases
Based on our analysis of TriZetto’s existing features and user reviews, we have identified these scenarios where the platform may fit:
1. A Practice That Loses Its Clearinghouse Suddenly And Cannot Afford Weeks Of Unbilled Claims
When a clearinghouse becomes unavailable or a contract ends unexpectedly, practices still need to submit claims and meet payer filing deadlines. TriZetto’s direct connections with EHR and practice management software provide an established route for sending claims and receiving transactions, without needing a new connection to be created from the beginning. The capability could be useful for billing teams where even a short interruption can leave claims waiting to be submitted and delay reimbursement.
2. Specialty Practices Managing Payer-specific Authorization Guidelines
TriZetto can fit specialty practices where authorization requirements differ across payers and the required documentation needs to be established before care is scheduled. It uses Health Level 7 (HL7) FHIR-based APIs to support Coverage Requirements Discovery, Documentation Templates and Rules, and Prior Authorization Support through the provider’s clinical system. This lets staff identify payer criteria and collect the relevant documentation before submitting an authorization request. For specialties such as imaging, orthopedics, or oncology, that can help keep authorization requirements tied to the service being scheduled rather than handled as a separate payer lookup.
3. Revenue Teams Managing Claims Through Several Payer Portals
In multi-payer practices and billing organizations, TriZetto can give AR teams a more direct way to follow claims. Its Claim Status Inquiry lets staff request claim status through the system rather than checking individual payer portals or calling payer lines. The team can review the returned payer information in one place and determine whether a claim is still processing, needs follow-up, or requires another action. This could make payer follow-up easier to organize for teams managing a large aging claim queue.
4. Provider Groups Finding Reimbursement Below Contracted Payer Rates
The software can be useful when a provider group needs to determine whether payer payments are matching its contracted rates. Contract Manager compares actual reimbursement with payer-specific contract terms and pricing rules, allowing revenue teams to see payment variances at the claim level. Advanced Reimbursement Manager Pro can further surface underpayments, late payments, and incorrect clinical edits. These functionalities give the group a way to trace reimbursement gaps back to specific payer and payment trends during contract reviews and negotiations.
Is TriZetto Right For You?
TriZetto may be a fit for practices handling growing claim volumes, complex payer arrangements, and broader data exchange needs. Its Clinical Data Exchange Solution uses HL7 FHIR-based APIs and Da Vinci Implementation Guides to support near real-time data exchange between providers and payers.
The platform also connects with Cognizant’s TriZetto Facets, QNXT, and CareAdvance payer solutions. This could be useful for organizations adding locations, clinical systems, or payer-facing processes that require standardized clinical exchange.
Its clearinghouse complies with SOC 2, EHNAC, and HITRUST standards, helping organizations submit claims securely and efficiently.
Still doubtful if TriZetto is the right fit for you? Connect with us at (661) 384-7070 for further guidance.
TriZetto Features
Patient Responsibility Estimation
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.
Prior Authorization
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.
Patient Payments
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.
Rejection And Denial Prevention
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
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.
Pros And Cons of TriZetto
Pros
Rejection details can return quickly, helping teams correct and resubmit claims sooner
Users frequently remarked on helpfulness of the support staff
Detailed reporting gives teams more visibility into claim and payment data
Shortcuts help make navigation quicker
Batch processing supports organizations handling high claim volumes
Cons
Initial setup may take some time
Some workflows require navigating multiple screens
Customization options may be limited for some requirements
TriZetto Reviews
Total 1 reviews
4
All reviews are from verified customers
Rating Distribution
5
Stars0%
4
Stars100%
3
Stars0%
2
Stars0%
1
Stars0%
Share your experience
Anonymous
Not Specified, N/A employees
“Better safety and patient access”
Pros
Switching to electronic records has brought real long-term savings for me by cutting down on paperwork, improving staff efficiency and lowering office supply and day-to-day operating costs. It also does a lot for patient involvement since the portal lets people view their health information, book appointments and message their providers directly. On top of that, safety features such as medication warnings and allergy alerts help reduce mistakes and support safer patient care.
Cons
Getting everyone comfortable with the system takes time and staff usually need training before they can fully adjust to the new technology. During that transition, productivity can dip a bit. There are also valid concerns around data security since EHR systems can be exposed to cyber threats and data breaches which means strong protections and constant monitoring are necessary.
Rating Distribution
Ease of use
7
Value for money
8
Customer Support
8
Functionality
8
Frequently Asked Questions
Who are the typical users of TriZetto?
TriZetto features are used by hospitals, clinics, physician practices, billing services, and medical groups.
Does TriZetto have a mobile app?
No, it doesn’t offer a mobile app.
What level of support does TriZetto offer?
TriZetto offers support via phone and email.
What other apps does TriZetto integrate with?
It integrates with several practice management and EMR systems such as eClinicalWorks, NextGen Enterprise EHR, EZClaim, and more.
What languages does TriZetto support?
TriZetto software is primarily available in English.
Does TriZetto offer an API?
Yes, TriZetto provides API access.
What types of pricing plans does TriZetto offer?
TriZetto pricing starts at approximately $300/month. Its plans can be customized to meet the unique requirements of different organizations. Get in touch for a tailored TriZetto cost estimate.