With the implementation of risk-adjusted payment methodologies for Medicare plans, complete and accurate submission and tracking of claims, encounter and prescription drug event (PDE) data are critical for the following reasons:

• Claims and encounter data are the basis of the risk scores that the Centers for Medicare and Medicaid Services calculates for each member (for both Part C and Part D payments) and are the critical drivers of your revenue stream
• PDE data drives the retroactive reconciliation of Part D payments as well as ongoing benefit/adjudication levels for members

However, submitting the data poses significant challenges, as CMS has stringent requirements on format, contents and interrelationships of data elements. If these aren’t met, data can be rejected impacting the revenue stream a plan receives from CMS. TriZetto offers comprehensive solutions for RAPS, encounter and PDE data management.

These solutions help Medicare Advantage and Part D plans record and submit data, and track and resolve discrepancies, streamlining the reconciliation process and improving efficiency. TriZetto’s comprehensive solution includes three key applications:

• Claims Data Manager: Submits RAPs claims data, tracks results, and provides tools that can correct and resubmit claims for Part C and Part D risk-adjustment.
• Medical Data Express-Xpress Encounter Pro™: Interfaces with TriZetto applications and provides extraction, delivery, tracking, reporting, editing and resolution of encounter data.
• PDE Data Manager: Submits PDE data, tracks results, and provides tools that correct and resubmit PDE data. It also aggregates PDE data in support of Part D retroactive reconciliation.

• Ensures that data is submitted in CMS-required formats
• Helps the plan correct discrepancies that can result in reduced CMS payment
• Meets needs for Part C and Part D risk-adjustment as well as Part D retroactive reconciliation