Skip to main content Skip to footer
Medicare/Medicaid Member Enrollment & Risk Solutions

Power up your government lines of business

Meeting the complex data processing and compliance requirements of Medicare Advantage, managed Medicaid and commercial exchanges in a timely manner is critical to your success.
Our products extend the functionality of your core systems, providing critical capabilities from enrollment through encounter submissions to efficiently drive these lines of business forward.
Strengthen financial integrity
Strengthen financial integrity

Gain visibility into MA/DSNP dollars with unified payment accuracy, CMS encounter reconciliation and efficient audits to control revenue, reduce leakage and protect margins.

Dollar sign with circular arrows icon
Reduce operational risk
Reduce operational risk

Adapt quickly to evolving CMS guidance and state mandates with fewer manual touchpoints and audit-ready documentation. When regulations shift, you move confidently rather than scrambling to respond.

Connected arrows and pathways icon
Accelerate strategic agility
Accelerate strategic agility

Align finance, care and quality teams around one view of performance to make faster decisions, scale MA/DSNP growth, optimize provider networks and pursue new value-based opportunities.

Three gears icon
Automate encounter data workflows
Automate encounter data workflows

Streamline CMS and Medicaid submissions with business rules, automated error correction and HIPAA validation. EDM reduces manual effort, improves compliance accuracy and supports timely, audit-ready reporting.

Circular arrow with forward path icon
Ensure enrollment accuracy at scale
Ensure enrollment accuracy at scale

TriZetto Enrollment Administration Manager (EAM) automates intake-to-submission workflows, validates eligibility and integrates with QNXT and Facets to reduce rejections, improve data quality and secure premium dollars.

Checklist and pencil icon
Accelerate implementation timelines
Accelerate implementation timelines

Implement EDM and EAM in as little as 10–12 weeks with prebuilt configurations and seamless integrations that speed go-live, accelerate ROI and reduce customization and deployment risk.

Upward arrows icon
Boost audit readiness and transparency
Boost audit readiness and transparency

TriZetto Elements® suite solutions provide dashboards, workflow monitoring and automated reporting that help health plans track submissions, correct errors and maintain compliance with CMS and state mandates.

Stacked documents icon
Drive measurable enrollment improvements
Drive measurable enrollment improvements

Clients achieved an 85% first-pass enrollment rate and eliminated 100% of duplicate CMS DTRRs after migrating to EAM and Facets demonstrating the power of automation and integration.

Multiple upward pathways icon
Scale confidently with proven solutions
Scale confidently with proven solutions

Elements suite supports health plans across 39 states and processes billions of transactions annually. Its scalability and regulatory alignment make it ideal for growing MA and Medicaid programs.

Gear with digital circuit icon

TriZetto Elements suite

Cognizant’s TriZetto Elements suite helps Medicare Advantage and Medicaid plans automate critical administrative processes risk adjustment, encounter data, enrollment, and financial reconciliation. Each solution is purpose built to reduce errors, improve compliance and protect revenue across CMS programs.

  • TriZetto Enrollment Administration Manager, powered by TriZetto Enrollment Administration Manager Workflow

    Enrollment accuracy is foundational to CMS compliance and payment integrity. EAM automates intake to submission workflows, integrates with core systems and ensures real-time eligibility checks to reduce rejections and improve member data accuracy:

    • Automates end-to-end enrollment and disenrollment workflows
    • Integrates with QNXT and Facets for bidirectional data exchange
    • Maintains 100% CMS compliance with real-time updates and validations
  • TriZetto Financial Reconciliation Manager

    Aligning payments with actual risk and enrollment data is key to financial health. Financial Reconciliation Manager helps plans reconcile CMS payments and adjustments, and subsidies minimizing leakage and supporting audit-ready transparency:

    • Automates reconciliation of premiums, subsidies, and adjustments
    • Flags discrepancies and supports audit documentation 
    • Strengthens payment integrity and reduces revenue variance
  • TriZetto Encounter Data Manager and TriZetto Encounter Data Manager Workflow

    Accurate encounter data is essential for CMS reporting and revenue protection. EDM automates validation, correction and submission workflows reducing manual effort and improving compliance across Medicare, Medicaid and exchange plans:

    • Automates error resolution and regulatory rule enforcement
    • Tracks submission status and exceptions in real time
    • Supports 95%+ compliance accuracy and 30% reduction in manual effort
  • TriZetto Risk Score Manager

    Risk score accuracy drives reimbursement. RSM calculates and reconciles Part C and D risk scores using CMS methodologies, while TriZetto Intelligent Suspect Identifier uncovers undocumented HCCs to improve coding completeness and forecasting:

    • Ingests EDPS, MORs, RxMORs and core data for score calculation
    • Identifies suspect HCCs using machine learning and clinical logic
    • Improves abstraction performance and audit readiness

Connected operations for accuracy and accountability

Cognizant’s TriZetto Elements suite connects seamlessly with core administration and quality platforms to create a unified operational backbone for government programs. Each integration ensures that compliance, payments and performance move together—improving accuracy, reducing rework and strengthening plan confidence in CMS-facing operations.

Accuracy in CMS operations begins with consistent, real-time data. By connecting Elements suite with TriZetto QNXT and Facets, health plans gain a unified operational view across enrollment, encounter and reconciliation workflows:

  • Synchronizes member, eligibility and payment data across platforms
  • Minimizes duplicate record handling and manual reconciliation
  • Improves CMS acceptance rates and audit transparency through consistent data flow

This connection helps government plans strengthen their financial control and streamline administrative performance—ensuring every transaction is accurate, compliant and traceable.

Quality and financial performance are two sides of the same equation. Through its integration with TriZetto ClaimSphere® suite, Elements suite links operational accuracy with quality improvement, helping plans understand how clean data and efficient submissions translate into higher HEDIS and Star Ratings:

  • Connects claims, encounter and quality data for a single source of truth
  • Improves visibility into the financial impact of quality performance
  • Supports continuous improvement by aligning compliance and care outcomes

This interoperability allows government plans to manage quality and cost together—building a stronger foundation for value-based success.

When quality data stays siloed, its impact is limited. By integrating TriZetto ClaimSphere with Facets and QNXT, health plans gain a single, trusted view of member performance across administrative, clinical and quality domains:

  • ClaimSphere unifies data from claims, encounters and clinical sources, translating it into actionable quality metrics that feed directly into Facets and QNXT environments
  • Facets and QNXT embed these insights into administrative workflows, creating a single source of truth for eligibility, claims processing and performance tracking

Together, these platforms help health plans reduce data discrepancies, align quality insights with operational decisions and strengthen the link between care outcomes, member experience and business performance.

Latest thinking

TriZetto Elements suite resources
TriZetto Enrollment Administration Manager brochure

Explore how EAM automates enrollment workflows, integrates with QNXT and Facets, and supports CMS compliance through FHIR®-based data exchange and real-time eligibility checks. Learn how connected workstreams and automated correspondence improve member experience and operational efficiency.

Learn more
Two professionals reviewing a tablet
TriZetto Encounter Data Manager data sheet

Dive into EDM’s capabilities for automating encounter validation, error correction and HIPAA compliance. Discover how 200+ prebuilt rules, real-time dashboards and workflow automation help health plans reduce costs, improve accuracy and meet CMS and Medicaid requirements across 39 states.

Learn more
Healthcare professional assisting an older adult with a tablet
The Medicare Advantage landscape

Challenges, risks and the move to value-based care.

Learn more
medicare-advantage-landscape

HL7®, and HL7® FHIR® are registered trademarks of Health Level Seven International, and their use of these trademarks does not constitute an endorsement by HL7.

Take the first step

Serving customers by looking forward as well as back is a big promise, but the power of today’s new digital healthcare solutions is vast and growing. Our expertise in healthcare IT services enables us to integrate cutting-edge technology seamlessly into your operations.

Let’s talk about how digital healthcare IT solutions can work for your business.