2. TriZetto QNXT Workflow
Marty Newton V.P. Product Portfolio Management
David Symonds Lead Solutions Specialist

3. Session Agenda TriZetto Workflow QNXT Claim Workflow
QNXT Appeals and Grievances Workflow
Future QNXT Workflow Plans

4. TriZetto Commitment to Workflow
High priority during development
No additional 3rd party licenses required
Total Cost of Ownership
Designed to work across TriZetto portfolio of solutions
Reusability
Enrollment
Claims UM
A&G
Bringing solutions together through workflow integration

5. QNXT TMS EDM Future TriZetto Workflow Claim Workflow EAM Workflow
A&G Workflow
Claim Workflow
UM Workflow
Enrollment Workflow
Future Workflow
TMS
EAM Workflow
Future Workflow
EDM
EDM Workflow
Future Workflow
Future
Future Workflow

6. QNXT Claim Workflow

7. QNXT Claim Workflow Introduced in 2014 with QNXT 5.2
Agile development roll-out
Introduced in 2014 with QNXT 5.2
Client TCO top priority
Developed by TriZetto specifically for healthcare
No 3rd party investment required
TriZetto Workflow Engine
New technology
Improved user experience
Model for future QNXT module redesigns
Improved development environment
Improved integrations
QNXT Claims UI

8. QNXT Claim Workflow Data Qualifiers
Claim id
Log date
Adjudicate date
Clean date
Birthdate
Gender
Last name
VIP status
Insured id
Carriermemid (member id)
Dx code
Occurrence span code (UB)
Occurrence start date (UB)
Occurrence thru date (UB)
ICD procedure code
Condition codes (UB)
Final DRG code (UB)
Line of business
Claim status
Claim edit
Claim source
Claim Form type
Total charges
Type of bill (UB)
Admission date
Admission source
Admission type
Claim start date
Claim end date
Claim line
Edit severity
REV code
LTC
Benefit plan ID
Contract ID
Employer
Policy number
Discharge date
Discharge status

9. QNXT Claim Workflow Upcoming Features
Graphical view of productivity by user
Ability to set productivity targets
See productivity by user. See and modify what queues and roles that user belongs to.
Choice of time periods for which to set productivity targets
Daily
Weekly
Monthly
Quarterly
Annually

10. Future Claim Workflow Manager’s Dashboard

11. QNXT Claim Workflow Demo
David Symonds

12. QNXT Appeals & Grievances Workflow
Screen shots included are for demonstration/example purposes only, final product screens may vary

13. High Level Overview New A&G module with Workflow Engine will:
Track who and how grievance or appeal is requested
Track due dates based on assigned itineraries from Workflow
Attach related claims and/or Authorizations
User View of all cases assigned to Coordinator
Manager’s Dashboard View
New A&G module with Workflow Engine will:
Initiate “Case” from Call Tracking
Set different level steps to route and set due dates based on SLA
Itineraries configured in Workflow Engine
A&G Coordinators
Review group or users involved in process
Groups and Users configured in Workflow Engine

14. QNXT A&G Solution QNXT Call Tracking QNXT A&G Module QNXT Core
Optional 3rd Party Partner
New License
QNXT Call Tracking
TriZetto Workflow Engine
QNXT A&G Module
Document Management
QNXT Core
“Call” Source
Call Type
Initial Notes
Route Case
Case Level
Case Itinerary
Priority
Queues
Dashboard
Case details
Notes
Dates
Documents
Claim UM
Member
Provider
Case Review
Disposition
Search
Reports
Inbound
Outbound
Document Workflow
TCS

15. Call Tracking Entry

16. A&G Entry

17. A&G User Console

18. A&G User Console with items “at risk”

19. A&G User Console w/ user tasks

20. A&G User Console – Grievances w/ “at risk”

21. QNXT A&G Workflow Timeline
Currently in development
Scheduled initial release on November 4, 2015

22. Future QNXT Workflow

23. QNXT UM & Enrollment Workflow
New UIs
Single page data entry – removal of wizards
Save work “in process”
Similar “themes” across QNXT modules when introducing workflow
Claim to UM
A&G to Claim, UM, Member
Workflow engine will coordinate across QNXT modules, for example
Auth creation
Nurse/Medical Director review
Documentation required
UM Workflow

24. Thank You