Transcript Document

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Copyright © 2014 TriZetto Corporation
QNXT General Session
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Copyright © 2014 TriZetto Corporation
Welcome
New Clients since last TriZetto Health Care Conference…
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Copyright © 2014 TriZetto Corporation
Agenda
 Introductions
 QUser Board
 Where are we now? – QNXT
 QNXT™ T3 Update
 Workflow
 What else is new?
 Closing
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Copyright © 2014 TriZetto Corporation
Quser Presentation
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Copyright © 2014 TriZetto Corporation
QUsers
 Welcome
 QUsers Group
 Formally organized in 2006
 Established for the purpose of exchanging ideas, best practices,
and solutions to provide quality, cost-effective health plan
administration.
 Provide the forum to share information to maximize the
effectiveness and use of the QNXT™ suite of products and
services.
 Promote QNXT best use and future direction in a forum of
collaboration and partnership between TriZetto and its
customers
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2014 / 2015 Goals and Objectives
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Membership Drive
Reduced Membership Dues
Increased Networking
Active Sub-Committees
ICD10 Implementation
CORE Certifications
ACA Mandates
QNXT™ Enhancement Voting
Software Quality and Support
Product Demonstrations
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Copyright © 2014 TriZetto Corporation
2014 / 2015 Board of Directors
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President
Vice President/Events
Treasurer
Membership
QUG CX Portal /
Communication
Susan Butts, Cox HealthPlans
Gail Doran, PHPNI
Eric Smith, Capital Health Plan
Sharon Perkins, El Paso First
Sharon Perkins, El Paso First
 Member-at-Large
Linda Katagiri, HMSA
 TriZetto Reps
Dale Hoerle/Jon Price, TriZetto
 Two New Board Members
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Welcome New Board Member
Frank Barresi
CIO Information Technology
Fallon Health
As CIO Frank is responsible for the overall delivery and support of IT services for Fallon. Technology areas include:
Enterprise Architecture, Enterprise Infrastructure, Application Development Support and Quality Assurance,
Business Systems Analysis, Project Management Office, and eBusiness & Digital Services.
Frank has over 25 years IT experience and has served in a variety of IT leadership roles across Healthcare, Financial
Services and Consulting. Frank served as Vice President of IT at AmeriHealth Caritas in Philadelphia, PA and was
responsible for Infrastructure and IT Operations and building out a highly scalable platform and infrastructure to
support AmeriHealth’s growth in the Medicaid market across the U.S.
Frank served as CIO for CIGNA Pharmacy
management/TelDrug and CIGNA Behavioral Health at CIGNA, providing common leadership to develop a data
integration strategy within their medical business. Frank held senior leadership roles delivering CIGNA’s initial key
consumer-directed product, Choice Fund, integrating early innovations in their HSA, HRA and FSA as well as leading
the delivery of CIGNA’s first Provider portal within CIGNA’s eCommerce technology practice. Other key technology
domains and functions that Frank has experience with include: Information Delivery, Data Integration, Business
Analytics, Enterprise Architecture & Strategic Systems Planning in addition to Systems Design, Development &
Testing while at Andersen Consulting/Arthur Andersen, (now Accenture).
Frank graduated with a Bachelor of Arts in Physics from College of the Holy Cross in Worcester, Massachusetts. He
also earned an M.B.A. from the University of Connecticut in Storrs, Connecticut with a concentration in Management
& Organization.
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Welcome New Board Members
Louise McCagg
VP Information Technology
Cigna – Health Spring
Louise is a seasoned IT professional who has worked with QNXT since 2006, selecting and implementing the
application for Bravo Health. Her current responsibility includes all aspects of management of the application and
associated development efforts for Cigna-HealthSpring. Louise has developed expertise in Medicare Advantage,
Medicaid and Medicare-Medicaid Alignment Initiative plans, especially relating to administering these plans on
QNXT.
She has previously held positions on managed care, provider relations, contracting and operations teams with
Humana and United HealthCare.
Louise comments…
“I am interested in serving as a board member to deepen my knowledge of QNXT, make contacts with like folks at
other organizations, to have an active role in potential changes to QNXT and to share what I have learned about
QNXT, especially from the Medicare Advantage and Medicaid perspective.>
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Copyright © 2014 TriZetto Corporation
Seven Sub-Committees
 Best Practices/Regulatory—Susan Butts,
[email protected]
 Government Programs and Collaborators—Corine
Peterson, [email protected]
 ITS (Blues)—Open
 New Implementation—Lori Sowle, [email protected]
 Performance—Ken Leisey,
[email protected]
 Quality—John Harbourne, [email protected]
 CWS—Jason Strong, [email protected]
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Events
 Welcome to the Spring Conference
 Logistics
 QUsers Networking Lunch
 QUsers Home Room
 Introduction to Laura Pasteur
[email protected]
 Fall Conference Information
 YOUR conference
 Topics
 Case Studies
 Planning begins today
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QNXT™ Enhancement Requests
 Important Dates:
 5/27/14 – 7/22/14—Enhancement submissions via Customer
Exchange
 9/15/14 – 9/17/14—QUsers Group will review the enhancements
at the Fall Users Conference
 9/29/14 – 10/24/14—Open voting for enhancements via
Customer Exchange
 November TriZetto will review enhancements and
announce which will require business requirements
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QNXT™ Enhancement Requests
 All enhancements suggestions are welcome!
 Suggestions need only be a short summary outlining
the issue to be resolved or a new feature
 Instructions for enhancement submission and voting
can be found on Customer Exchange
Customer Exchange ➔ User Groups ➔ QUsers Groups ➔ Enhancement Survey
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QUser Membership: Who Are We?
 36 Health Plans
 Covered lives range from 10,000 to over 1 million
 Product lines: Commercial, Medicare, Medicaid, TPA,
Self-Funded, ACO and Dental
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QUsers: Customer Exchange
 Subcommittee
information
 Meetings
 Announcements
 Questions and
answers
 Documentation
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QUser Membership: How Do I Join?
Sharon Perkins
[email protected]
(915) 298-7198 x1103
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Where are we now –
QNXT™?
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TriZetto Organization: QNXT Bend
Jude Dieterman
President and
COO
Dale Hoerle
VP Software
Engineering and
CTO
Alan Stein
SVP Product
Management
Scott Hampel
VP Product
Management
Kathy Wiley
VP Product
Management
Todd Tipton
VP Portfolio
Management
Gary Cahill
AVP Sales
Overlay
Jon Price
AVP QNXT
Product Mgmt,
Sales and Mktg.
Marty Newton
VP Portfolio
Management
Derrick Drewry
Director Software
Engineering
Tom Kerns
SVP Consulting
Services
Eric Sommers
VP Consulting
Michael Pierce
VP Consulting
Karen Callahan
AVP Consulting
Marvin Matthews
AVP Consulting
Rob Scavo
SVP Markets
Rob Renzi
SVP Sales
Sal Gentile
Market President
 Alignment between TriZetto’s solutions and client
needs / requests
 Integration of TriZetto Provider Solution into T3
 Markets geographic focused model and the addition
of the Dedicated Account Management team
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Bottom Line Difference
Dale Hoerle
VP Software
Engineering and
CTO
Alan Stein
SVP Product
Management
Scott Hampel
VP Product
Management
Kathy Wiley
VP Product
Management
Todd Tipton
VP Portfolio
Management
Gary Cahill
AVP Sales
Overlay
Jon Price
AVP QNXT
Product Mgmt,
Sales and Mktg.
Marty Newton
VP Portfolio
Management
More efficient
organization
Derrick Drewry
Director Software
Engineering
Tom Kerns
SVP Consulting
Services
Eric Sommers
VP Consulting
Michael Pierce
VP Consulting
Karen Callahan
AVP Consulting
Marvin Matthews
AVP Consulting
New solution
opportunities
Rob Scavo
SVP Markets
Rob Renzi
SVP Sales
Sal Gentile
Market President
Working with
people you
know
 Alignment between TriZetto’s solutions and client
needs / requests
 Integration of TriZetto Provider Solution into T3
 Markets geographic focused model and the addition
of the Dedicated Account Management team
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Copyright © 2014 TriZetto Corporation
Release Cadence
 History – Yearly
 Big jumps with lots of enhancements to take on
 Then 8 weeks, like clockwork
 Got us thinking and moving agilely
 Allowed us to bring new features, more quickly
 Was not always easy for you to keep up
 Now 13 weeks
 Blending the two
 Still allows to think and act agilely
 Allows us bring new features to you quickly
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What We’ve Delivered Since Last Year
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Exchange Enhancements
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Tax Credits
Subsidy
Premium Billing Support
834 Readiness
270 / 271 Member Grace Period
A/R Past Due
Cost Share Adjudication
APTC Grace Period
834 Non-Exchange
Compliance
Enhancement(s)
Claim Form Enhancements
ITS Real Time Home
SQL 2012 Support
EFT Support
CAE Integration
5010 Connect Agent Update
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Medicare Enrollment
Sequestration
Multiple Grouper / Single
Program
Input / Output XML
viewer
ITS 14.0
Melissa Geo-Coding
Interface with TTPS
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270/271 Real Time
276/277 Real Time
270/271 Grace Period
iCES – Institutional
Claims Support
iCES – 5.0 Upgrade
SQL Injection Protection
Config Option Module
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CARC/RARC
Prevention of
Authorization Bypass
834 Dependent Term
Rules, Retro Term
A/R Account
Consolidation
TMS ICD-10 Support
Select Contract by Pay-To
Affiliation, not PCP
Micro-Dyn ICD-10 ASC
PRICERActive
SHOP Broker
Claims Workflow Content
Micro-Dyn Grouper
BizTalk 2013
Fee Table Search
Government Programs
Regulatory
Administrative Efficiency
Integration
ITS
Technology
LEGEND
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T3 Update
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QNXT™ Quality Review
 Defect Backlog Reduction
 Client Reported May 2013: 237
 Client Reported May 2014: 87
 No Client Severity 1 since April 2012
 Client Reported Severity 2’s
 2012: 23.5 per month
 2013: 13.54 per month
 2014 to-date: 7.25 per month
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2012.10.06
2012.10.20
2012.11.03
2012.11.17
2012.12.01
2012.12.15
2012.12.29
2013.01.12
2013.01.26
2013.02.09
2013.02.23
2013.03.09
2013.03.23
2013.04.06
2013.04.20
2013.05.04
2013.05.18
2013.06.01
2013.06.15
2013.06.29
2013.07.13
2013.07.27
2013.08.10
2013.08.24
2013.09.07
2013.09.21
2013.10.05
2013.10.19
2013.11.02
2013.11.16
2013.11.30
2013.12.14
2013.12.28
2014.01.11
2014.01.25
2014.02.08
2014.02.22
2014.03.08
2014.03.22
2014.04.05
2014.04.19
QNXT™ Quality Review
QNXT Weekly Open Defect Trending
800
700
600
500
400
Defect backlog
300
25
Internal Found
Client Reported
200
100
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QNXT™ Quality Review
QNXT Defects Opened By YYMM and Origin
120
100
80
60
Internally Found
Client Reported
40
20
0
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QNXT™ Quality Review
Client Reported QNXT 2009-2013 Defects by Component
400
350 338
2009
Defects
2010
Defects
2011
Defects
2012
Defects
2013
Defects
300
C
o
u
n
t
250
200
150
100
50
198
183
173
130 131
84
89
73
59
43
114
104
85
54
103
86 79
49
44
32 25
77
75 82
62
60
54 48
49
17
67
54
3127
25
25 232224
12
46
40
33
29
28
23 24 1616
139 17810
12 2014411 22617118 211114149 71715
10
0
0
Components
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QNXT™ Support: Incident Event Survey
 95% of respondents were satisfied with accuracy of
resolution
 Took too long to assign your incident to a support
expert
 What are we doing about it?
 In October 2013, we had 180 unassigned incidents
 In April 2014, we have 0
 How can you help?
 Engage us early during your upgrade process
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QNXT™ Incident Backlog: Then and Now
 October 2013
 410 incidents in the backlog with 180 unassigned
 April 2014
 320 incidents in the backlog with 0 unassigned
 We did it while training 5 new associates!
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QNXT™ Resolving Incidents Within SLG
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October 2013 met SLG 58% of the time
March 2014 met SLG 64% of the time
April 2014 met SLG ??% of the time
Goal is to be at 80% by July
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Architectural Advancement
Integrations
QNXT UI
Custom Code
RESTful Web Services
QNXT
Business
Domain
Unit
Tests
Data
Storage
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Architectural Advancement
 Domain Driven Design
 All business related logic and decisions centralized into Domain
 Business rules, processes and procedures
 Business and technology experts collaborate throughout the
Domain building process
 Technological decisions can reside outside of core Domain logic
 Changing a UI to a different platform
 Changing the data storage to another vendor
 Agnostic to development processes
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Architectural Advancement
 RESTful Web Services
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Extensibility layer that exposes Domain logic
Follows HTTP web standards to ease integrations
New QNXT UI, other software integrations and custom code
Lightweight transport options for better performance and
scalability
Copyright © 2014 TriZetto Corporation
Architectural Advancement UI Overview
Browser Z
Browser X
Browser Y
Patient:
Provider:
Save
Patient:
Provider:
Patient:
Provider:
From Date:
Save To Date:
Save
Content Server
Web API Server
Domain Logic Server
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Web API Server
Architectural Advancement UI
 Angular JS
 Future proof JavaScript Library provided by Google
 Set to support current and future web technologies
 Enforces strict decoupling of business logic from UI logic
 Minimizes future maintenance complexities
 Supports Unit Testing
 Build robust, flexible code base that can withstand change
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Architectural Advancement UI
 Bootstrap
 Create flexible, cross browser user experience
 Support for Responsive Design
 Built-in support for mobile platforms including tablets and
phones
 Reacts to changes to browser window size on desktop
platforms
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QNXT Workflow™
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Copyright © 2014 TriZetto Corporation
TriZetto’s Workflow Product Experience
 TriZetto created a proprietary workflow engine that is
in use today
 Facets Workflow™ solution in use today by more
than 50% of Facets clients
 TriZetto leveraging what has been learned through
Facets Workflow
 TriZetto has built a new Workflow rules engine
modeled after our existing solution
 New technology
 New services
 New web UI
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What is QNXT Workflow™ for Claims?
 Real Time
 Automated
 Integrated
 Configurable
 Work Prioritization
 User Queues
 Manager Dashboard
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How it works…
 Claim workflow is called “in-line” during QNXT adjudication no separate batch processes required
 Configurable rules and data elements used to identify claims in
need of workflow
 The process will act upon the claim in real time
 Identify claims by QNXT edits
 Identify claims using non-edit related data
 Prioritize claims using multiple criteria
 Manually route claims
 Route claims to specific user or user group queues
 Role based user queue assignment
 Flexible configuration provides options for work groups or individual
queues
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How it works…
 Introducing a new QNXT Claim UI
 Existing QNXT Claim UI still available
 QNXT Workflow for Claims uses a new claim UI
 New QNXT Claims UI sets the model for future QNXT UI
updates and improvements
 QNXT Claims Examiners/Users
 New “Get Next” claim feature
 Next claim to be worked is identified based on Workflow rules
 Edit
 Priority
 User Role
 Other
 Existing QNXT “Claims Workflow” module will
remain but will be renamed.
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Go from this…
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To this…
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QNXT Workflow™
Product Snapshot
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Workflow Role Definition
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Workflow Queue Rules
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QNXT™ Queue Roles
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Workflow Routing Rules
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Workflow Qualifier Groups
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Workflow Administration
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Workflow Manager Dashboard
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QNXT Workflow™ History
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QNXT™ Claim Search
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QNXT™ Claim
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QNXT Workflow™ Release Schedule
 Initial delivery August 2014
 General
availability November 2014
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QNXT Workflow™
Proof of Concept Demo
Monday 1:15
TriZetto Innovations Gallery
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What Else is New?
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Market Focused
 QNXT Workgroups
 QNXT Development (T3) will facilitate Product Workgroups
 Content will focus on;
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Current features and functionality
Future enhancements
Forum for demos, requirements gathering, feedback, lessons learned
Open to all QNXT clients and TriZetto Colleagues
 Active Product Workgroups include
 Exchanges
 Candidates for future Product Workgroups
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Connect
Technology
Performance
Medi-Cal
TMS/EAM
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Workflow
Usability
QXI
Pricing
Duals
 Volunteers for QNXT 5.1 R7
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QNXT™ Roadmap: 12 Month View
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QNXT™ Roadmap: 12 Month View
Regulatory
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Government
Programs
Integrations
Administrative
Efficiency
Technology
Regulatory
 ADA Form
 ACA / Operating Rule
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Claims Attachments
834
820
278
837
QNXT 5.2 Volunteer Candidate
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Government Programs
 Exchange Support
 SHOP 834
 Broker support
 Group Load
 Dual Eligibles Support
 Division Of Financial Responsibility
(DOFR)
 HIX / HIPAA 820 Inbound
 Physician 9 Digit Zip Code
 Medicare Procedure Payment Reduction
(MPPR)
 Therapy
 Imaging
QNXT 5.2 Volunteer Candidate
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Integrations
 TriZetto Workflow
 NetworX®
 Pricer
 Payment Bundling
 TriZetto Communication System
 Micro-Dyn ESRD
 McKesson ClaimsXten
QNXT 5.2 Volunteer Candidate
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Administrative Efficiency
 QNXT™ Customer Voted Enhancements
 Multiple Co-Pay
 Auth Matching – Denied Auths
 Configurable Provider Types – Auth Matching
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Advanced Capitation
Accumulator Access
Archiving Support – Static Accumulation
TriZetto Workflow Connectors
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Member / Enrollment
EDI / Batch Processing
Provider
Authorization
QNXT 5.2 Volunteer Candidate
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Technology
 .NET 4.5
 MicroSoft Internet Explorer 10 / 11
support
 Cumulative Installs (MSI/MSP)
 SQL Injection Protection
 Authentication Bypass with Forceful
Browsing
 Privilege Escalation / Authorization
Bypass
 Windows 2012 Support
QNXT 5.2 Volunteer Candidate
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QNXT™ Roadmap: 24 Month View
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Closing
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Thanks and don’t forget to see………
SOLUTION
CENTER AND
EXHIBITS
 TriZetto Products
 Exhibits
 Partner Sessions
BREAKOUT
SESSIONS
 TriZetto
Integrations
CLIENT
SUCCESS
STORIES
 ICD 10 – The last
mile
 QNXT Reform
USER GROUP
MEETINGS
 Adoption Leaders
Program
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QUser Group
Meeting
Thank You!
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