-- A --
Application bundle - A set of pre-integrated, best-of-class applications that provide enterprise-wide functionality otherwise not attainable through any one application.
Application service provider (ASP) - As defined by TriZetto, an ASP (or "hosting organization") integrates, hosts, monitors, and manages the best healthcare applications from multiple vendors in its own data centers and delivers these applications to customers via frame relay, a dedicated line, virtual private network, satellite or the Internet for a predictable monthly fee. (See "Hosting.")
-- B --
Benefits administrator (BA) - Manages the design and administration of benefits plans for organizations that self-fund their health, dental, and/or disability plans. Unlike insurance companies, the benefits administrator does not assume financial risk. Typical services offered by a benefits administrator include claims processing, plan design, performance analysis, employee enrollment, production of plan documents, and management of specific and aggregate reinsurance coverage.
Blue Cross and Blue Shield Association (BCBSA) - An organization composed of 45 independent, locally operated Blue Cross and Blue Shield plans that collectively provide healthcare coverage to 80 million or one in four Americans. TriZetto has a five-year national agreement with BCBSA that provides for the association to offer information on TriZetto's HealthWeb® Internet platform to its member plans.
Business process outsourcing (BPO) - Managing the technology and providing the staff required for an entire business process. In healthcare, customers typically choose to outsource processes such as member enrollment, billing, and claims processing.
-- C --
Capitation - A method of payment whereby a physician or hospital is paid a fixed amount for each person in a particular plan, regardless of the frequency or type of service provided. The physician is paid on a monthly basis after being selected by a member of that HMO.
ClaimFacts® - TriZetto's managed indemnity solution that provides high-volume, reliable and cost-effective claims processing.
ClaimsExchange™ - A TriZetto service that allows payers and benefits administrators to electronically transmit and receive claim information to/from external preferred provider organizations (PPOs). This vastly improves the speed and accuracy of the claims re-pricing process and also eliminates the need for payers to maintain PPO provider lists and contract terms within their core systems.
Claims processing - Refers to the procedure followed by a payer to pay for a treatment or procedure received by a member covered by an insurance policy. Members or providers submit claims.
Code sets - Under HIPAA, a code set is any set of codes used in administrative and financial healthcare transactions to describe data elements, including medical diagnoses, concepts, and procedures; type of health facility or medical unit; or race/ethnicity of a patient. Uniform code sets are designed to reduce coding errors, produce consistent reporting, and increase the efficiency of the healthcare system. Congress recently extended the compliance date for electronic transaction and code sets by one year to Oct. 16, 2003, if healthcare organizations submit a summary to federal officials explaining how they will use the extra year to reach compliance. If a summary is not submitted, organizations must still comply by the original Oct. 16, 2002, deadline.
-- D --
Data warehouse - A collection of data that supports decision-making. Unlike data used in an online transaction processing system, warehouse data is usually subject-specific, historic, and non-volatile. A data warehouse usually contains many years of data.
-- E --
Earnings before interest, taxes, depreciation and amortization (EBITDA) - When a company is EBITDA positive, it can cover all its operating expenses without borrowing funds from outside sources.
E-Business - Any business activity that is conducted electronically via the Internet. This includes buying and selling, servicing customers, and collaborating with business partners. For example, via e-business, a provider or health-plan member can check eligibility, update records or check on the status of a claim. Via e-business, a patient can also schedule a physician appointment online or download treatment information.
E-Commerce - This is a type of e-business focused on buying and selling goods via an electronic, Internet-based method. For example, a physician's office conducts e-commerce when it orders supplies via a Web site.
Electronic data interchange (EDI) - The electronic exchange of information between two business concerns (or trading partners) in a specific, predetermined, standard format. The exchange occurs in messages called transaction sets and usually involves business documents, such as claim forms and eligibility rosters.
Enterprise software - Software products designed to integrate core business processes (e.g., membership, claims, provider-network management, and billing) across an enterprise. TriZetto can host software that complements our core enterprise applications (e.g., Facets) to provide comprehensive enterprise-software solutions for healthcare companies.
-- F --
Facets® - TriZetto's industry-leading client-server system for managed healthcare payers. Facets managed-care administrative software is used by nearly one-third of all Blue Cross and Blue Shield organizations.
-- G --
GroupFacts® - TriZetto's managed indemnity solution that provides high-volume, reliable, and cost-effective group life/health administration.
-- H --
Health Care Financing Administration (HCFA) - The agency responsible for administering Medicare and overseeing states' administration of Medicaid.
Health Insurance Portability and Accountability Act (HIPAA) - This legislation was signed in 1996 to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs through specific administrative-simplification provisions. These provisions apply to a wide variety of issues involving electronically transmitted health information. They include national standards for electronic transmissions, security, and privacy. HIPAA touches virtually all segments of the healthcare industry. TriZetto has a company-wide, internal, HIPAA-compliance initiative. It also offers training, consulting and HIPAA Gateway™ software for customers.
Health maintenance organization (HMO) - The term used to describe payer organizations that form a network of physicians and hospitals, and contract with them for lower rates on patient care. HMOs focus on preventive care and maintaining health, in addition to treating illnesses. Primary care physicians (PCPs) are generally used as gatekeepers to direct patients to appropriate, cost-effective care. Obtaining care without a PCP's referral, or obtaining care from a non-network provider, usually results in nonpayment for services by the HMO.
Health Plan and Employer Data Information Set (HEDIS) - A performance measurement used by HMOs that gives a numerical score for how well a health plan serves its members. This information is used by employer groups when selecting a health plan for their employees.
HealthWeb® - TriZetto's Internet platform that allows health plans to exchange information and conduct business with providers, members, employers and brokers on a secure basis over the Internet. HealthWeb also helps create online "self-service," reducing delays and phone calls, and increasing customer satisfaction through prompt access to key information. HealthWeb has been pre-integrated with major administrative systems and can work with virtually any health plan's legacy system.
HIPAA Gateway™ - TriZetto's HIPAA solution that acts as a repository, allowing customers to capture and access the supplemental data required by HIPAA but not necessary for core transactions. For example, the system checks each transaction submitted by a provider for compliance with HIPAA regulations before it's passed to the base system for processing. The gateway is pre-integrated with TriZetto products and supports both electronic data interchange and Internet transactions. It also works with non-TriZetto systems.
Hosting - Hosting refers to managing software applications for customers from a remote location. A hosting organization (or "application service provider") provides the data center in which the hosted applications operate and takes responsibility for monitoring the applications, as well as the related hardware and networks. (See "Application service provider.")
-- I --
Indemnity insurance - A traditional health insurance plan with little or no benefit management, a fee-for-service reimbursement model, and few restrictions on provider selection.
Information technology outsourcing (ITO) - Refers to a business arrangement in which a customer decides to outsource its entire information technology operation to another company such as TriZetto.
Integrated Healthcare Management (IHM) - The systematic application of processes and shared information to optimize the coordination of benefits and care for the healthcare consumer.
-- L --
Legacy application - An application in which a company or organization has already invested considerable time and money. Typically, legacy applications are database management systems running on mainframe or mini computers. An important feature of new software applications is their ability to work with legacy applications or import data from them.
-- M --
Managed care organization (MCO) - A health plan that uses financial incentives and management controls to direct patients to providers who are responsible for giving appropriate care in cost-effective treatment settings. The goal is to improve quality of care while controlling the cost of healthcare. Managed care organizations include health maintenance organizations (HMOs) and preferred provider organizations (PPOs).
Managed services organization (MSO) - An autonomous entity created to manage a number of aspects of physician practices, including finance and accounting services, and contract negotiations with subcontractors and managed care plans. Among other goals, MSOs strive to improve operating efficiencies and enhance revenue for physician practices.
-- N --
National Committee for Quality Assurance (NCQA) - A nonprofit group that reviews and accredits managed care and other organizations for quality improvement, utilization management, and other functions. TriZetto's NCVO® division is NCQA accredited.
NCVO® - A division of TriZetto that provides physician credentials verification services and application processing for health plans and health-plan consortiums.
NetworX™ - A TriZetto claims re-pricing system that provides automation, advanced technology, and network-claims-processing efficiencies for preferred provider organizations and healthcare payers. NetworX can be licensed or hosted.
-- O --
Operational data store (ODS) - An integrated database that contains current or near-term operational data, i.e., usually 30 to 90 days of information.
-- P --
Payer - An organization that pays for healthcare services covered under a specific insurance plan. Examples include HMOs, private insurance companies (such as John Hancock), employers, and the government.
Per member per month (PMPM) - How healthcare payers and providers account for revenue and costs. For example, healthcare payers receive $X per member per month from employee groups; they pay physicians and other providers $Y pmpm to provide services.
Point-of-service (POS) - A type of benefit plan that combines features of HMO and indemnity insurance. Members must select a primary care physician who is part of the plan's network and pay a co-pay at each visit. The primary care physician coordinates members' care and refers them to specialists and healthcare facilities within the network. Members may use physicians who are not part of the network but this triggers indemnity-style coverage, under which the member must first meet a deductible and, thereafter, pay a percentage of total fees.
Preferred provider organization (PPO) - A managed care organization that allows members to seek care from in-network physicians without having to designate a primary care physician. As a result, members are not required to obtain a referral before visiting another physician or specialist within the network. Members are allowed to see physicians who are not part of the network but at greater cost.
Pre-integrated - The process of creating the integration and maintaining interoperability between core and satellite applications. For example, TriZetto's HIPAA Gateway is pre-integrated with Facets and other core applications.
Preventive care - Care that is given to prevent illness. Examples are annual physicals, Pap smears, and education or support groups for those trying to lose weight or quit smoking.
Primary care physician (PCP) - A primary care physician specializes in overall "family" healthcare. PCPs are typically family practitioners, general internists, pediatricians, and sometimes ob/gyns. Generally, a PCP supervises, coordinates, and provides medical care to members of a health plan. The PCP may also initiate all referrals for specialty care.
Procedure code - Standard codes used by all hospitals, physicians, and healthcare organizations to describe medical procedures. Payers can match procedure codes with diagnosis codes to ensure that the proper care was given.
Provider - One who provides medical care, usually a physician or hospital.
-- Q --
QicLink™ - TriZetto's software engine that automates the healthcare-claim-payment process for benefits administrators. QicLink is the industry's leading application for health benefits administrators. It can be licensed or hosted.
-- R --
Re-pricing - The process of researching a previously negotiated rate and attaching it to a submitted claim. This process takes place between payers and PPO networks. For example, when a payer (i.e., a health plan, benefits administrator or third-party administrator) receives a claim from a physician belonging to a PPO network, the payer transfers the claim to the physician's PPO network. The PPO is responsible for changing the price on the claim according to the rates it previously negotiated with the physician. The PPO then submits the re-priced claim to the payer for processing. TriZetto's NetworX product automates this complex process between PPOs and payers.
-- S --
Satellite application - A specialized software application used in conjunction with core business applications. TriZetto integrates third-party satellite applications with core business applications such as Facets.
Service-level agreement (SLA) - A minimum level of service guaranteed to a customer receiving hosted services. An SLA incorporates financial penalties if not met.
Software engines - Powerhouse, enterprise-level applications that run core processes and mission-critical functions.
-- T --
Third-party administrator (TPA) - A corporate entity that handles group benefits, claims, and administration for a self-insured company or group. TPAs arrange for reinsurance coverage, contract with physician/hospital networks, and manage the claims-payment process. Generally, a large corporation or benefits administrator might contract with a TPA to design and administer a customized health plan. (See "Benefits Administrator.")
-- U --
Utilization management (UM) - A form of case management and claims review where the insurance company analyzes a case to determine if the treatment given was appropriate or necessary.
-- W --
Web-enable - To equip a traditional, standalone application with connectivity to the Internet using a Web browser.
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