First-Pass Claims Rate Soars as Major Healthcare Plan Implements TriZetto Facets Workflow

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

Challenge: Maximizing Efficiency in Claims Workflow Management

The client needed to optimize their claims processing by implementing TriZetto Facets Workflow while transitioning from their legacy system. They faced several critical challenges:

• Legacy claims processing relied on basic Facets functionality and custom IT jobs
• No dedicated resources available for Facets Workflow requirements gathering
• Lack of documented processes and testing procedures
• Need for more robust and efficient claims routing capabilities
• Required extensive Facets Workflow knowledge transfer to new staff

The organization needed a partner with deep TriZetto Facets expertise who could not only implement the new workflow system but also establish proper Requirement and Design documentation and Configuration knowledge transfer while working with limited internal resources.

Solution: Comprehensive Workflow Implementation and Enhancement

Alivia implemented a multi-phase approach to address both immediate needs and long-term sustainability:

Phase 1:

1. Led requirements gathering and design sessions
2. Developed comprehensive Requirement and Design documentation
3. Created testing frameworks and procedures
4. Implemented core workflow functionality
5. Established knowledge transfer processes to Configuration Team with no knowledge of Workflow.

Phase 2: Process Optimization and Enhancement

1. Enhanced existing workflow configurations
2. Implemented additional automation
3. Reduced manual routing requirements
4. Optimized claim routing efficiency
5. Created positions for ongoing support

Our team took ownership of the entire process, from initial requirements gathering through post-implementation support, creating a foundation for sustainable operations.s 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: Implementation Leadership and Process Development

Throughout the engagement, Alivia provided:

• Requirements and design leadership
• Testing procedure development
• Documentation creation
• Knowledge transfer programs
• Staff training and development
• Process improvement recommendations

We helped create and train two new positions dedicated to supporting the workflow system, ensuring long-term sustainability of the improvements.

Outcome:  Increased Efficiency and Sustainable Operations

In Phase 1, we successfully transitioned existing claims processing to the TriZetto Facets Workflow system, maintaining operational continuity while achieving initial efficiency gains through improved claim routing and reduced manual touches.

Building on this foundation, Phase 2 delivered significant process enhancements. Our team analyzed 19,332 claims across 25 unique pend scenarios, leading to nine critical process improvements. Key improvements included redesigning the Provider Match logic and implementing new Workflow functionality, further optimizing claims processing efficiency.

The implementation and optimization increased first-pass adjudication rates while enhancing pended claim routing efficiency. Both phases were completed under budget, with comprehensive documentation and sustainable infrastructure established.

The team also created a complete testing department framework, including test plan templates, issue resolution processes, testing management tools, and quality assurance procedures. This framework, combined with full process documentation, ensures long-term sustainability and continued optimization opportunities.