Major Healthcare Plan Achieves Rapid Claims Backlog Reduction Using TriZetto Facets

Client Snapshot: 375,000+ members | 21,000+ network physicians | 2,800+ sites of care

Challenge: Managing Complex Claims Backlog While Maintaining Quality Standards

The client encountered a significant claims adjudication backlog in their TriZetto Facets environment that threatened to impact their operations and provider relationships. Their internal Facets claims team was struggling to maintain the required production standards while ensuring 99% quality accuracy requirements were met.

The client needed a claims adjudication solution that could:

• Rapidly reduce a mounting TriZetto Facets claims backlog of over 120,000 claims
• Maintain strict quality standards (99% accuracy requirement) in Facets claims processing
• Handle complex coordination of benefits (COB) claims across multiple lines of business within Facets
• Provide experienced Facets claims processors who could adapt quickly to their specific processes

Solution: Specialized Claims Processing Team with Expertise-Driven Approach

When Alivia joined the project, we implemented a comprehensive solution that went beyond simple staff augmentation:

1. Deployed an expert claims processing team that could operate as an independent unit
2. Established dedicated claim supervisors to manage queues and daily operations
3. Created comprehensive documentation and training materials of previously undocumented processes
4. Implemented three rounds of specialized training to handle increasingly complex claim types
5. Identified and documented potential process improvements and automation opportunities
6. Provided strategic recommendations for system configuration changes

Our team operated as an autonomous claims department, managing their own workflows while meeting all client quality and production standards. This approach allowed for seamless integration with existing operations while maintaining independent efficiency.

Alivia’s Role: Strategic Partner in Claims Operations

As a strategic partner, Alivia delivered:

Outcome: Dramatic Reduction in Claims Backlog with Process Improvements

Working alongside the client’s team, our experts contributed significantly to the backlog reduction effort. Our team resolved 21,000+ claims while maintaining a manual resolution pace of over 3,500 claims per week. Configuration changes improved efficiency for 13,313 claims, representing a 15% gain in overall processing capacity. Together with the client’s efforts, the total backlog was reduced from 85,718 to 32,148 claims.

The partnership delivered exceptional outcomes, with the team maintaining 99% quality standards while efficiently processing complex COB claims across multiple business lines.

Alivia developed comprehensive documentation, implemented key process improvements, and reduced manual claim touches through strategic automation. The partnership’s value was ultimately validated when the client re-engaged the team after the initial project completion.