More on Claims Processing

New TriZetto portal to link providers with payers

One of the pain points in the payment of healthcare bills is the process of gaining approval from insurers for medical procedures. The TriZetto Group is looking to ease that pain by introducing a better means of communication between providers and payers.

The Greenwood Village, Colo.-based developer of healthcare IT solutions last week announced the upcoming launch of CareAdvance Provider, the newest component of its CareAdvance Enterprise care management suite. The new automated authorization portal is designed to enable direct communication between providers and payers through Web portals that providers already use, allowing them to determine more quickly which treatments will be covered by the patient's health plan.

"The CareAdvance Provider system continues TriZetto's focus on delivering solutions to improve administrative efficiency and the cost and quality of care," said Jeff Rideout, TriZetto's chief medical officer and senior vice president of cost and care management, in a Sept. 30 press release announcing the upcoming launch of CareAdvance Provider. "By automating healthcare service requests using the pre-determined rules each payer creates and maintains, payers and practitioners can reduce unwarranted variations in care as well as administrative headaches. Additionally, by giving practitioners more access to clinical information and standardizing the authorization process, parties likely will see improvements in the consistency and efficiency of utilization management, as well as care management overall."

According to TriZetto officials, when a provider submits an authorization request through the new portal, a CareAdvance Provider solution replies with a pre-determined set of questions. The provider's answers to those questions generate a score based on the patient's benefit plan, enabling the provider to determine whether the authorization will be approved, denied or filed for additional review.

The question-and-answer process will also be filed in a Medical Clinical Profile, a member-specific profile similar to an electronic medical record, that will enable the provider to chart medications, claims history and other factors that may affect the quality of care provided to the patient.

"The power of the CareAdvance Provider software lies in the provider self-service, which can greatly reduce the lengthy and costly process practitioners often face when seeking pre-authorization for a medical service," Rideout said. "With this new solution, practitioners' workflow is automated with two-way communication regarding the authorization request-for-services without the need for phone calls or manual processes, like mailing or faxing forms. The information they need to enhance their workflow, including the Member Clinical Profile, will be available in the CareAdvance Provider system."

"By giving practitioners greater participation in the authorization process, this new solution can help control cost to support reform mandates, enable patient-centered medical home programs and reduce the administrative burden of many over-taxed provider offices," he concluded.

The CareAdvance Provider portal is the third application in TriZetto's CareAdvance Enterprise suite, joining Clinical CareAdvance and Personal CareAdvance. It will be available in December.