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Helping healthcare organizations transform operations by reducing costs, streamlining processes and enhancing patient care services.

Our deep relationships with leading healthcare organizations around the world put us in a unique position to deliver services through our integrated IT/BPO model. Our HC BPS practice:

  • Processes more than 55 million claims annually, including more than 3 million Medicaid claims
  • Provides operational solutions to shorten time-to-market and enhance revenue by supporting acquisition, retention and growth of the membership base
  • Reduces administrative costs through streamlined processes and transformational initiatives
  • Provides access to talented resources and skillsets including claims, licensed agents, ICD, CMS, Medicare and clinicians


Clinical Services

Our Clinical Services practice helps payers and providers better manage their medical management services and reduce the operational cost of providing wellness and care management services. With licensed clinicians and URAC certified centers, our global delivery model enables solutions that include:

  • Pre-Authorization
  • Utilization Management
  • Nurse Helpline (Voice /Web)
  • Member Outreach
  • Wellness programs
  • Case Management
  • Disease Management

Membership Services 

Our focus is on creating customer-centric and transformational operating models for Healthcare companies to better manage their membership services. Our solutions increase quality, improve turnaround time and drive productivity. 

Services include:

  • Enrollment Processing
  • Benefit Coding & Testing
  • Agent Licensing
  • Premium Billing & Reconciliation
  • Process Optimization
  • Cycle time reduction through the use of G-COV

Claims & Provider Services

Services include:

  • Front End Processing
  • Claims Processing
  • Adjustments/COB Processing
  • Provider Data Management
  • Credentialing / Re-credentialing
  • Provider Contract Management
  • Network Management
  • Fraud and Abuse Management
  • Clinical Review of Claims
  • Medical Bill Review
  • Pre-Authorization
  • ICD-10 Business Services
  • Billing
  • Accounts Receivable
  • Payment Posting & Reconciliation
  • Credit Balance & Refunds
  • Tele-Radiology

Pharmacy & Intermediaries 

Pharmacies & Intermediaries services include:

  • Claims Processing
  • Enrollment / Eligibility
  • Provider / Payer Enrollment
  • EDI Claims Support
  • Pharmacy Benefit Coding 

Consumer Rights and Responsibilities:

Consumer Rights:

  • To be treated with dignity and respect.
  • To receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each and prospects for recovery in terms that are understandable to the consumer, in order to give informed consent or to refuse that course of treatment.
  • To every consideration of privacy and to expect that all communications and records related to his/her care will be treated as confidential.
  • To be given access to the utilization management department for timely responses to questions and requests made for service.
  • To be given information on how to file a complaint.
  • To be informed of utilization management policies including how to file an appeal with your insurance company when requested.
  • To be informed of utilization management criteria used to authorize, modify or deny healthcare services when requested.

Consumer Responsibilities:

  • To be familiar with the benefits and exclusions of the consumer’s health plan coverage.
  • To provide the consumer’s healthcare provider with complete and accurate information regarding past illnesses, hospitalizations, medications and other matters related to health status.
  • To treat the utilization management staff with respect and dignity.

Utilization Management:

Utilization Review Plan

Cognizant’s Global Clinical Services Utilization Management program provides clients with a framework for monitoring the use of healthcare resources and evaluating the appropriateness of care that is seamless to their members. The UM Plan Summary defines the goals, structure, accountability, scope and other components of Cognizant’s UM program.


Read entire summary


Improving compliance and reducing penalties to create an efficient claims process

Learn how Cognizant helped a leading national health insurer reduce its pend rate from 13.8% to 4%, resulting in improved claim finalization rates and driving more on-time payments to providers.                         

Beating industry benchmarks through analytics and process re-engineering

Learn how Cognizant identified process rationalization opportunities to reengineer the workflow of a leading health information and research company from a case-based approach to an activity-based approach.                          

HealthCare Services | Business Process Services | Cognizant Technology Solutions