QicLink Enterprise™ Close-Up

  • medium-3man-1woman-jpg-362x246.jpgEnhance automation.  —Keep systems running smoothly.

    The QicLink™ application provides extraordinary functionality and flexibility, giving TPAs the tools they need to reduce costs and improve efficiency. A comprehensive and integrated solution, the QicLink application can help you reduce costs through greater automation, increased auto-adjudication and reduced manual intervention in claims processing.

    Get rapid ROI — while you improve quality.

    This advanced core solution empowers you to achieve rapid ROI by enabling your organization to maximize auto-adjudication rates and reduce claims processing costs. The QicLink application also can help your organization support compliance with ICD-10 and other healthcare regulations as well as:

    • Manage claims through their full life cycle.
    • Improve productivity by enhancing workflows.
    • Enable smooth transactions between your providers and members.
    • Adjudicate plan designs that range from simple to highly complex.
    • Manage risk and support quality-of-care initiatives with affordable, innovative, pre-integrated TriZetto Premier Partner solutions.


    Customize QicLink with modular components.

    The QicLink application provides a range of integrated components that enable you to tailor the solution to the specific needs of your business.


    A logic matrix that supports procedure-driven adjudication, efficient plan building and ease of maintenance, letting you avoid the costs and hassles of creating your own own rules and templates. ClaimRules utilizes a Universal Decision Matrix (UDM ) containing a comprehensive set of claim rules and provides a universal plan using the same benefit coding structure as the UDM. This plan utilizes an extensive set of benefit codes to ensure consistent claims processing. By using ClaimRules, large cost savings may be achieved by dramatically shortening the process of implementing a procedure driven plan and allowing efficient and consistent claims payment.

    ClaimsExchange® Service

    The first re-pricing solution available via the Internet, the TriZetto ClaimsExchange service seamlessly connects benefits administrators to a vast network of PPOs—routing claims and re-pricing data electronically through a single point of connectivity. The ClaimsExchange service automates and simplifies the re-pricing process, minimizing paperwork, manual intervention and human errors. The result is a dramatic increase in auto-adjudication rates as well as significantly reduced administrative costs. Additional capabilities provide an automated solution for obtaining discounts on out-of-network claims via a post-adjudication electronic interface with fee negotiators that further reduces adjustments due to ineligible claims.


    Improves productivity in claims adjudication by accepting claims/encounter data from multiple sources and in multiple formats, based on business-process rules established by your organization. ClaimWorkflow allows users to achieve cost savings through automation and remarkable adjudication efficiencies.


    A clinical-editing component that automatically checks claims during adjudication and calls attention to unusual or unnecessary treatment patterns. ClinicaLogic analyzes current claims in the context of complete episodes of care and patient history while automating the identification and extraction of claim and related data for editing. It adheres to care and billing standards established by national medical societies yet offers you the flexibility to customize parameters for claims editing in order to comply with your unique provider-payment policies and guidelines. Changes recommended by ClinicaLogic typically reduce processing costs by as much as 15 percent.

    Customer Service

    The Customer Service module is a Web-based solution that improves both the efficiency and quality of your client service efforts. Known as WebCSR, the module lets your team log, track and report on telephone calls more easily using point-and-click functionality, drop-down boxes, scroll lists, and multiple sort-and-display options. When a call opens or closes, the module automatically populates the call number, open/close date, time, and employee fields. An enrollee/member screen displays extensive information such as demographics, coverage, address, COB, and student information. It also provides a warning when HIPAA privacy information exists for the member.


    Provides superior data-analysis capabilities. You can access data using powerful relational-database reporting capabilities and using e-query tools to create reports that enable your organization to stay agile.

    Cost Containment

    Provides numerous reports that meet your organization's strategic business requirements and cost-reporting needs. User-designed reports broaden your analyses through automated, flexible, data-sort sequences and can include even more data for your specific requirements, when you need it.

    Premium Billing

    Automates your billing while supporting electronic fund transfer (EFT). The solution also automates premium payments and enables you to calculate options for multi-level agent commissions. When late enrollment notifications are received, the component automatically calculates and adjusts invoices. When invoices are paid, it updates carrier and agent files. The Billing module also provides complete 1099 tracking for processing of agent and vendor commissions.

    Utilization Management

    Tools to manage any type of service — such as an inpatient stay or a specific procedure — for any setting. You can also create specific episodes, linked together on the case, for the various types of services required during the treatment period. Referral and authorization data from external sources can also be accepted and linked to a claim payment automatically.