Transcript Document
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Confidential
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Copyright © 2014 TriZetto Corporation
What’s New and Coming
in NetworX
Tonia Burns, AVP Product Management
Deb Nelson, VP NetworX Development
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Copyright © 2014 TriZetto Corporation
What have you done for me lately?
A trip down memory lane
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Copyright © 2014 TriZetto Corporation
Additional ICD-10 Processing Logic
Additional logic for ICD-10 Processing
Option to use the “ICD-10 Date” for Qualifier Group check only
Option to use the “ICD-10 Date” for Qualifier Group check and
claim/line qualifying and pricing
Drive logic by System Property “Qualify on ICD-10 Date”
“Y” claim pricing should be based on ICD-9/ICD-10 code in
qualifier group (on or after ICD-10 Date, use 10, before, use
9)
“N” claim pricing should be based on the submitted code
(ICD-9/ICD-10) regardless of the date
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Global Rate Sheet/Agreement
Provides the ability to create “standard” terms to be used in multiple
Agreements/Rate sheets
Create as many Global Rate Sheet/Agreements as needed, limited by
Agreement/Rate Sheet section
Make changes/add new terms in Global Rate Sheet/Agreement
Any Rate Sheet/Agreement using the Global Rate Sheet/Agreement inherits the
change
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RESTful service in Stand Alone Pricer
Clients have an option to use RESTful or standard
(WSDL) for processing electronic claims in Stand
Alone NetworX Pricer
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New Optum™ Prospective Payment
System (PPS) available
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Outpatient Group/Price Only
TRICARE (Inpatient and Outpatient)
Texas Medicaid (Inpatient – APR-DRG)
Medicare Physician
Illinois Medicaid (Inpatient)
Georgia Medicaid (Inpatient)
Michigan Medicaid (Inpatient)
Washington Medicaid (Inpatient)
Kansas Medicaid (Inpatient)
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Copyright © 2014 TriZetto Corporation
Web UI in Stand Alone Pricer
Pricer functionality in Web UI
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Rate Sheets
Global Rate Sheet
Qualifier Groups
Codes
Calculation Categories
Schedules
Test Price
Copyright © 2014 TriZetto Corporation
New Qualifiers
Provide the ability to qualify based on Rendering
Provider information
NPI
Taxonomy
Type
Specialty (Primary and Secondary)
Tax ID
ID
Patient Reason For Visit Qualifier
ICD-9
ICD-10
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New Calculations
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Stop Loss Lesser of Allowed or Per Diem
DRG with Base Rate and Med-Ed Rate
DRG with Base Rate and Length of Stay Inlier
Manual Stop Loss and Outlier – Retain Prior Pricing
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Copyright © 2014 TriZetto Corporation
Upgrades to Optum™ V1303 Web
Services
Support for ICD-10, including the new Code Class input field
Support for 64-bit
Ability to update Optum™ rate files without performing an IIS
reset
New NY Medicaid APR-DRG and Medicare ESRD pricing
worksheets
New external data file for Return Code labels and other labels
(outpatient only)
New input fields for inpatient claims only, including:
Line-level National Drug Code (NDC)
Used for Medicare Acute Care claims new technology reimbursement
Admission Date
Used to calculate claim length of stay taking into consideration the new
72 hour rule for billing outpatient services on an inpatient claim
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Copyright © 2014 TriZetto Corporation
3M™ Grouper Plus System (GPS)
Users can access 3M™ GPS through new NetworX
calculations
Claims submitted through service to 3M™ GPS
Calculation, claim data and term data “tell” GPS what process
and provide data
Claim returned to NetworX via the service with appropriate data
(DRG code, edits, pricing, etc., based on process performed)
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Perform Edit/Group functionality
Enter value for type of grouping to perform
(currently, MS-DRG and APR-DRG available)
Enter User Key 1 (required) and User Key 2
(optional) values matching records in GPS
For Medicare DRG, select to apply/not apply
POA/HAC Processing
Process will return the appropriate DRG to use for
other processing
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Perform Edit/Group for Outpatient
Processes
Enter value for type of grouping to perform
(currently EAPG available)
Enter User Key 1 (required) and User Key 2
(optional) values matching records in GPS
Select editing option
Process will return appropriate outpatient value for
claim lines
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EAPG Edit/Group/Price
Enter value for EAPG Edit/Group/Price to perform
(currently Wellmark and Virginia available)
Enter User Key 1 (required) and User Key 2
(optional) values matching records in GPS
Select editing option
Process will apply appropriate edits, EAPG code and
Pricing
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Enhanced PBA (5.10.004.000 and up)
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Updated technology
Remove dependency on IHMF
Improved UI- .Net to Java
HCI3 Prometheus
New optional package– 23 episodes supported
Patient Bundles
Filters
Total Episode Price, Budget, Variance and break out by NonComplications and Complications
Additional patient bundle details visible when patient bundle is open
Episodes & Episode Definition
Filters
Publish capability
Improved usability
Test Price
New tool available to price claims and see bundling results immediately.
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Copyright © 2014 TriZetto Corporation
Enhanced PBA (5.10.004.000 and up)
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Test Price
New tool available to price claims and see bundling results immediately.
Claim Re-Evaluation (Facets integration)
Codes
Cancel Reason Codes
Category Codes
Administration
Subscriber Configuration
Data Import
Security
Roles/Users
Configuration & Processing
Improved usability
Line level processing
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Copyright © 2014 TriZetto Corporation
The Small Print…
The development release and timing of any features or
functionality described for our products remains at TriZetto’s sole
discretion.
This information is intended to outline our general product
direction and it should not be relied on in making a purchasing
decision.
This information is not a commitment, promise or legal obligation
to deliver any material, code, or functionality.
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NetworX Roadmap
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Copyright © 2014 TriZetto Corporation
Workshop Survey
We would like to extend you an opportunity
to provide candid feedback.
During the workshop you should have 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.
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