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            Automation Saves the Hardest Work for the Pros

            The Challenge

            Texas Children’s Hospital, Texas Children’s Health Plan (TCHP), is the nation’s first health maintenance organization created just for children. This fast-growing children’s health organization took on a new line of business to better serve its member needs. While TCHP knew that its new service line would help it better care for sick children, the organization was challenged when faced with the anticipated need to increase staffing from 350 professionals to more than 1,100 in less than a year. To increase efficiency, administrators decided to leverage automation significantly to enable its claims examiners to manage existing work plus the new workload.

            Meanwhile, TCHP saw an opportunity to address its difficulties with the required processing of a monthly data load that was error-prone, time-consuming and costly. The health organization engaged Cognizant’s TriZetto team to increase claims processing throughput using automation.

            Our Approach

            Our TriZetto consulting services helped the TCHP model process workflows, validate payment accuracy on test claims and manage and monitor day-to-day activity. We also implemented our Healthcare Process Automation solution to process the low-to-medium complexity work that represents the bulk of claims received and tuned it to process many common edits.

            To address the issues with the Texas 834 EDI file data load, our Electronic Data Interchange team helped clean the data and fine-tune automation processes to load the files and reduce the amount of human intervention required.

            Software Robots Become the Backbone of Claims Processing

            Today, software robots log on to TCHP’s system each day to process hundreds of claims automatically. The combination of our hosted technology, advanced automation and consulting services support has enabled the organization to significantly grow its business without adding headcount, paying expensive overtime or sacrificing quality. With costs controlled, more money is available to ensure quality member experiences.


            reduction in claims backlog in a single week


            per month, per examiner cost savings over six months


            reduction in time for processing the monthly file, from four days to overnight

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