1. Confidential | Copyright © 2014 TriZetto Corporation 1

2. 2 ClaimsExchange ® A Multifaceted Tool Jenni Lynn and Sandi Frederick

3. Confidential | Copyright © 2014 TriZetto Corporation 3 What is ClaimsExchange?  Connects Payers to PPOs for electronic claims repricing  Multifaceted tool  Multilayered, multidimensional, versatile and comprehensive  Complex, complicated, involved  Hosted java based application  Fully Integrated with QicLink™ and FACETS™  Real time web service interface with NetworX ®

4. Confidential | Copyright © 2014 TriZetto Corporation 4 Benefits  Real time interface to QicLink™  Flexible matching for eligibility and providers  Automated workflow solutions  One connection point to multiple trading partners  Savings opportunities  Potential revenue stream  Comprehensive Reporting

5. Confidential | Copyright © 2014 TriZetto Corporation 5 Agenda  Pre-Adjudication  Post Adjudication Solutions  Reporting  Enhancements  User Group meeting

6. Confidential | Copyright © 2014 TriZetto Corporation 6 Pre-Adjudication

7. Confidential | Copyright © 2014 TriZetto Corporation 7 Pre-Adjudication - Claim Acquisition  837 Batch  4010 – 997 available  5010 – 997 available  THG  4010  5010  ECSIF  Post Adjudication ECSIF  Pre-adjudication

8. Confidential | Copyright © 2014 TriZetto Corporation 8 Pre-Adjudication – Data Entry

9. Confidential | Copyright © 2014 TriZetto Corporation 9 Pre-Adjudication - Real Time Matching  Real-Time Eligibility and Provider matching  Using SQL  Configurable settings  Eligibility Matching Options  SSN, Member ID or both (order can be defined)  Define number of characters to use for Member ID  Search Like IDs

10. Confidential | Copyright © 2014 TriZetto Corporation 10 Pre-Adjudication - Real Time Matching  Original Provider Matching Options  Match using Tax ID, NPI or both (order can be defined)  Name match is required  Address – Sequential or exact match  Use Service or Billing address  Define number of characters to use for provider name  Require Rendering Provider match  Ignore Rendering Provider for match

11. Confidential | Copyright © 2014 TriZetto Corporation 11 Pre-Adjudication - Real Time Matching  New Provider Matching Option  Independent of other matching options  Separate criteria for Institutional versus Professional  Flexibility accommodates unique data issues  Map claim data elements to QicLink™ fields for matching  Require few or many data elements  Multiple passes with unique criteria - Ranking

12. Confidential | Copyright © 2014 TriZetto Corporation 12 Pre-Adjudication - Real Time Matching

13. Confidential | Copyright © 2014 TriZetto Corporation 13 Pre-Adjudication - Real Time Matching Claim Information  Billing provider  NPI, TIN, NAME, LAST, FIRST, ADDR1 ADDR2, CITY, STATE, ZIP  PayTo provider  NPI, TIN, NAME, ADDR1, ADDR2, CITY, STATE, ZIP  Practice provider (service or facility)  NPI, TIN, NAME, ADDR1, ADDR2, CITY, STATE, ZIP  Referring provider  NPI  Rendering  NPI, TIN, LAST, FIRST  Print checks to  Specialty  Status QicLink™ provider fields  Sequence number  Provider ID  NPI  First name  Last name  Address 1 & Address 2  City, State, Zip  Status  Term date  Print check  Alfa 1 & 2  Suffix  Category  Specialty code 1 & 2  Tax ID  835Option

14. Confidential | Copyright © 2014 TriZetto Corporation 14 Pre-Adjudication - Real Time Matching  Internal sequence numbers exported  THG, Batch 837 and ECSIF  CBJ bypasses matching  Multiple directories supported  Export includes  PCM code of repricing entity  EOB codes - QicLink™ remark codes  PPO comments can be exported or suppressed

15. Confidential | Copyright © 2014 TriZetto Corporation 15  Eliminate manual processes and paper handling  Complex sorting decisions made automatically  Over 100 data elements with unlimited combinations to use for routing  Apply business rules to streamline your workflow Pre-Adjudication – Automated Workflow

16. Confidential | Copyright © 2014 TriZetto Corporation 16 Automated Workflow – Routing Rules

17. Confidential | Copyright © 2014 TriZetto Corporation 17 Automated Workflow – Code Types  Age  ASA Code(s)  Claim Submitter Owner ID  Claim Status  Contract Network ID  CPT-4 Procedure Modifier Code(s)  DRG Code(s)  All Remaining Code(s)  Group Name  Group Number  Group Number Prefix  HCPCS Code(s)-Line  HCPCS Procedure Claim – All  ICD-9 Procedure-All  ICD-9 Diagnosis-Line  ICD-9 Diagnosis-Other  ICD-9 Diagnosis- Primary Code(s)  ICD-9 Diagnosis-All Code(s)  ICD-9 Procedure - Primary Code(s)  ICD-9 Procedure - Other Code(s)  Patient Name  Employment Related  Accident(Other) Related  Accident(Auto) Related  Insured ID  Provider Zip Code  Multiple Surgical Procedure Codes  Network Code  Place of Service Code(s)  Provider Zip Code(s) - 3 digits  Provider Type Code(s)  Provider ID(s)  Provider State(s)  QC2PlanNum  QC2ProviderComment  Contract Information Reference ID  Claim Routing Code(s)  Revenue Code(s)  Submitter ID  Submitter Type  Provider Specialty Code(s)  Type Of Service Code(s)  Type Of Bill Code(s) ETC … ETC …. ETC

18. Confidential | Copyright © 2014 TriZetto Corporation 18 Automated Workflow - Code Types

19. Confidential | Copyright © 2014 TriZetto Corporation 19 Applying the Functionality  Business Rule  Review Professional claims with final non-contracted determinations when the type of service is an ancillary type of service (x-ray, lab, anesthesia) performed in a hospital setting.  Logic  First qualifier – Non-contracted completed claims  Second qualifier – HCFA claim type  Third qualifier – procedure codes for ancillary services  Fourth qualifier – place of service

20. Confidential | Copyright © 2014 TriZetto Corporation 20 Code Group “Ancillary Services”: CPT-4 Procedure Code(s) - Line = 70010-89399,00100-01999 AND Place of Service Code(s) = 81,24,21-22 AND Claim Source Code = p,P,h,H Applying the Functionality

21. Confidential | Copyright © 2014 TriZetto Corporation 21 One Connection Typ PPO OOA PCP PPO OOA 2nd PC COB PPO L/P MOD PPO Cd Fund CkG M PPI PPI P/P y y p n n MTP / P/P / / / p n n JOD / P/M / / / p n n GAL / P/M / / / p n n / / / / / p n n Typ PPO OOA PCP PPO OOA 2nd PC COB PPO L/P MOD PPO Cd Fund CkG M PPI PPI P/P y y p n n MTP / P/P / / / p n n JOD / P/M / / / p n n GAL / P/M / / / p n n / / / / / p n n Eligibility matched and GBO information is pulled

22. Confidential | Copyright © 2014 TriZetto Corporation 22 One Connection  GBO, PMA and PCR is pulled  Multi-tiered routing until claim is completed

23. Confidential | Copyright © 2014 TriZetto Corporation 23 Post - Adjudication  Designed for discounts on out-of-network claims  Multi-tiered capability – stack your OON vendors  Claim selection after adjudication in QicLink™.  Claims are on hold in QicLink  Adjudication information extracted  No transaction fees to payer  EOB language requirements are automated

24. Confidential | Copyright © 2014 TriZetto Corporation 24 Post – Adjudication

25. Confidential | Copyright © 2014 TriZetto Corporation 25 Post - Adjudication

26. Confidential | Copyright © 2014 TriZetto Corporation 26 Post – Adjudication Claim Display Claim detail displays Charges, Allowed, Negotiated and Savings fields

27. Confidential | Copyright © 2014 TriZetto Corporation 27 QicLink™ XPARHM screen Repricing History Inquiry Screen xparhm Claim Number................. 9600103001 *Negotiated claim* Payer Claim ID................... PA9600103001 Original Process Date............ 08/20/2012 Date Sent to Out................. 08/20/2012 Date Returned.................... 08/20/2012 Original Allowable Charges....... 403.26 Negotiated Charge................ 223.20 Savings Amount................... 180.06 Contract Used.................... PHX

28. Confidential | Copyright © 2014 TriZetto Corporation 28 EOB Cross Reference

29. Confidential | Copyright © 2014 TriZetto Corporation 29 Post - Adjudication  Other Service offerings  Fraud Waste and Abuse review  Editing and Hospital Bill Review  Combine with Out of Network  Savings opportunities  Cost - Percent of savings to vendor  Transaction fees $.00  No cost unless savings are recognized

30. Confidential | Copyright © 2014 TriZetto Corporation 30 Post - Adjudication  Automated solutions  Option to select all claims by group or default  Separate exclusion programs  Claims on hold  No results – release to check cycle  Bill review update automated – hospital signoff  Editing and FWA recommendations  Routed for review and detailed vendor reports provided  Update to payment system manual

31. Confidential | Copyright © 2014 TriZetto Corporation 31 Post - Adjudication  Potential Revenue Stream  All solutions – FWA, Editing, Hospital Bill review and OON  ClaimsExchange fees - $0.00 for post adjudication  Vendor Agreement 25% of savings  Savings – Monthly - $100,000 Annual - $1,200,000  Vendor fee 25% – Monthly $25,000 Annual - $300,000  Administrative fee 5% – Monthly $5000 Annual - $60,000  Employer Group Net savings – $840,000 or 70%  Annual revenue - $60,000

32. Confidential | Copyright © 2014 TriZetto Corporation 32 Comprehensive Reporting  Crystal Reports through the application  Ability to export reports in all formats  Ability to export data only  32 standard reports  Report types  Inventory  Batch reconciliation  Productivity  Savings  Turnaround time

33. Confidential | Copyright © 2014 TriZetto Corporation 33 Comprehensive Reporting

34. Confidential | Copyright © 2014 TriZetto Corporation 34 Comprehensive Reporting

35. Confidential | Copyright © 2014 TriZetto Corporation 35 Enhancements  Q4 2013  14 Enhancements  6 internal  8 external  Q2 2014  22 Enhancements  7 internal  15 external

36. Confidential | Copyright © 2014 TriZetto Corporation 36 Enhancements  Q2 2014  Normalization of provider data  Custom interface for ACS - new trading partner  Provider matching  Strip special characters from all compare fields  Compare length options All, numeric, 1- 20  Compare defined values to 835 processing option  ECSIF Modifications  diagnosis codes, diagnosis pointer and total charges

37. Confidential | Copyright © 2014 TriZetto Corporation 37 Enhancements  Q2 2014  User Functionality  Reprice icon disabled for externally priced claims  Patient Plan now displays in contract information

38. Confidential | Copyright © 2014 TriZetto Corporation 38 Enhancements – HCFA 1500

39. Confidential | Copyright © 2014 TriZetto Corporation 39 Enhancements – HCFA 1500 Wizard

40. Confidential | Copyright © 2014 TriZetto Corporation 40 Enhancements – Search Option

41. Confidential | Copyright © 2014 TriZetto Corporation 41 Enhancements – Claim Inquiry  Claim Inquiry Enhancement  Initiate a claim inquiry search  Select a claim in error status  New target claim icon enabled  Click on icon  User is taken to mailbox  Selected claim is highlighted and user can work claim  Target icon has a green background  Requirements  Claim in error status  User has update claim permissions  User has access to the mailbox

42. Confidential | Copyright © 2014 TriZetto Corporation 42 Enhancements – Claim Inquiry

43. Confidential | Copyright © 2014 TriZetto Corporation 43 Enhancements What would you wish for?  ClaimsExchange ® User Group  Wednesday 10:30

44. Confidential | Copyright © 2014 TriZetto Corporation 44 Workshop Survey We would like to extend you an opportunity to provide candid feedback. During the workshop you should’ve received an e-mail notification for you to take an on-line survey. If you could take a few minutes to complete at this time, we would greatly value your feedback. For your convenience, the survey will be available throughout the remainder of the conference should you not be able to complete immediately.

45. Confidential | Copyright © 2014 TriZetto Corporation 45 Thank You!