QNXT work for plans running Medicaid, Medicare and delegated risk.
We configure and integrate TriZetto QNXT, the Cognizant core administration platform. Most of the work is benefit and provider configuration, feeds for the CMS-0057-F APIs, pilots of Cognizant's agentic claims features and staffing QNXT analysts who are hard to find.
QNXT Workflow, Open Access, DOFR Module, Dental Module
Agentic claims
Workflow Agentic Processing GA, 28 Sep 2026
release watch
Workflow Agentic Processing28 Sep 2026
TriZetto AI Gateway06 Aug 2025
connects with
in short·15-second read
TriZetto QNXT is Cognizant's cloud-based core administration platform for health plans, with modules for claims, membership and providers and add-ons such as QNXT Workflow and the DOFR Module.
Cohash configures and integrates QNXT. We build the data feeds behind the CMS-0057-F APIs that are due 1 January 2027, plan Workflow Agentic Processing pilots, and supply QNXT configuration analysts and developers.
you probably need this if
Delegated claims land with the wrong payer, because the DOFR rules haven't kept up with the contracts.
Prior authorization data sits in QNXT and the FHIR API deadline is close.
New plan-year benefits are configured late and tested by hand.
06 Aug 2025TriZetto AI Gateway Single access point for TriZetto software to work with AI agents, with SSO, role-based access and telemetry. source ↗
28 Sep 2026Workflow Agentic Processing It's GA for QNXT and for Facets. Agents clear the routine pended claims that are eligible, and they have more than 100 MCP tools to use. source ↗
today · Oct 22, 2026
01 Jan 2027aheadCMS-0057-F API deadline Provider Access, Payer-to-Payer and Prior Authorization APIs due for impacted payers. Operational provisions started 1 January 2026. source ↗
the story · trizetto qnxt estate
From the first call to a setup your own team can run.
Here's what usually prompts a call about your TriZetto QNXT estate, what we do about it and in which order, and where you end up.
01 · where it hurts02 · what we change03 · how it runs04 · where you end up
incident board · trizetto qnxt estate3 open
openDelegated claims land with the wrong payer, because the DOFR rules haven't kept up with the contracts.
recurringPrior authorization data sits in QNXT and the FHIR API deadline is close.
blockedNew plan-year benefits are configured late and tested by hand.
exposure
Benefit and provider configurationDOFR and delegated risk set-upCMS-0057-F API feedsIntegrations and EDIAgentic claims pilotsSpecialist staffing
startrehearsehandover
Configuration and interface…
Tests from your claims
API and data feeds
Pilot and handover
we are here
ready to hand over
Claims land on the right payer.
The API launches on agreed sources, and remaining data gaps have named owners.
DOFR rule review against current delegated contracts
Regression suite from your claims by line of business
chapter 01 · where it hurts
Why teams reach out
Delegated claims land with the wrong payer, because the DOFR rules haven't kept up with the contracts.
Prior authorization data sits in QNXT and the FHIR API deadline is close.
New plan-year benefits are configured late and tested by hand.
chapter 02 · what we change
How we solve it
Benefit and provider configuration
DOFR and delegated risk set-up
CMS-0057-F API feeds
Integrations and EDI
Agentic claims pilots
Specialist staffing
chapter 03 · how it runs
Our approach
Configuration and interface map
Tests from your claims
API and data feeds
Pilot and handover
chapter 04 · where you end up
What changes
Claims land on the right payer.
The API launches on agreed sources, and remaining data gaps have named owners.
DOFR rule review against current delegated contracts
Regression suite from your claims by line of business
what we do
Our TriZetto QNXT work
6 kinds of TriZetto QNXT work, each run by engineers who have done it on live tenants.
Benefit plans, provider contracts and pricing configured and tested against claims from your own lines of business.
Division of financial responsibility rules in the DOFR Module checked against your delegated contracts, so claims land on the right payer.
QNXT claims, enrollment and authorization data mapped to the Provider Access, Payer-to-Payer and Prior Authorization APIs, with feeds tested before January 2027.
Interfaces to care management, CRM, payment and broker systems, plus 834, 837 and 835 file flows with failure handling per partner.
A narrow Workflow Agentic Processing pilot on chosen pend reasons, with examiner review on denials and complex cases and agent access governed like any service identity.
QNXT configuration analysts, developers and testers, onsite in the US or from nearshore and offshore teams across time zones, within your data access rules.
capability 01 / 06in production
Benefit and provider configuration
Benefit plans, provider contracts and pricing configured and tested against claims from your own lines of business.
QNXT claims, enrollment and authorization data mapped to the Provider Access, Payer-to-Payer and Prior Authorization APIs, with feeds tested before January 2027.
A narrow Workflow Agentic Processing pilot on chosen pend reasons, with examiner review on denials and complex cases and agent access governed like any service identity.
QNXT configuration analysts, developers and testers, onsite in the US or from nearshore and offshore teams across time zones, within your data access rules.
We pieced these together from TriZetto QNXT situations that come up a lot. They're patterns. You won't find a specific client in them.
case file 01
Capitated claims paid by the plan instead of the delegated group
composite · not a client story
Beforethe situation
A Medicaid plan pays claims that its capitated groups should own. DOFR rules in QNXT were set up years ago and contracts have changed since, so recoveries pile up.
What we dothe work
We compare each delegated contract with the DOFR rules in QNXT, list mismatches and build test claims per contract. Fixes go through lower environments with finance signing off on expected liability.
Afterwhere you end up
Claims land on the right payer. DOFR changes are tested whenever a contract changes.
case file 02
Prior authorization data and a FHIR API due in January
composite · not a client story
Beforethe situation
Prior authorizations live in two places, QNXT and a separate utilization management tool. The Prior Authorization API is due by 1 January 2027, and nobody has decided which system owns each field.
What we dothe work
We map each field the API needs to its source, flag conflicts between the two systems and agree a source of truth with the business. Feeds are built and tested against real member records.
Afterwhere you end up
The API launches on agreed sources, and remaining data gaps have named owners.
We don't start a step until the last one has produced something you can check.
step 01
Configuration and interface map
We document benefit plans, provider contracts, DOFR rules, EDI partners and data consumers, so the dependencies are visible.
step 02
Tests from your claims
Regression cases come from your own claims by line of business, with expected pricing and liability results.
step 03
API and data feeds
We map QNXT data to the CMS-0057-F APIs and your reporting platform, list the gaps, and put an owner on each.
step 04
Pilot and handover
If Workflow Agentic Processing is on the table, start with one or two pend reasons. We hand over runbooks, test packs and access reviews at the end.
ai on trizetto qnxt
Where AI fits on TriZetto QNXT, and where it needs guardrails.
The same Cognizant AI features cover QNXT and Facets. On 28 September 2026 Workflow Agentic Processing became generally available for both. Agents get one controlled route into TriZetto software through the TriZetto AI Gateway. What a QNXT team has to decide is which pended claims agents may work and who reviews the others.
AI agentasks for data or an action
Scoped identityonly the access it needs
MCP serverthe one door into the platform
Logged, approveda person signs off on writes
TriZetto QNXTdoes the work
Agents reach QNXT through Cognizant's MCP tool library for Workflow Agentic Processing and through the TriZetto AI Gateway, which provides SSO, role-based access and telemetry. Give each agent its own identity and the fewest tools that work. Log every call. A human approves any claim change.
Workflow Agentic Processing on QNXT
Agents work routine pended claims by following the plan's standard procedures, and denials and complex cases go to examiners. We baseline volumes and handling steps per pend reason first. Then we pick queues with written procedures and outcomes that are easy to check.
TriZetto AI Gateway
Existing TriZetto clients got this in August 2025. It's one access point for TriZetto software to work with AI agents, and it comes with SSO, role-based access and telemetry. We set up the roles and connect sign-in to your identity provider. Telemetry is routed to your security monitoring.
More than 100 MCP tools
Cognizant's library has more than 100 MCP tools for claims operations. We classify every tool by what it reads and writes, give agents only the ones a pilot needs, and log each call for audit.
AI around QNXT
We use AI to document benefit and pricing configuration and to draft regression cases from recent claims before an upgrade. It also triages batch and EDI failures and maps QNXT data to the FHIR APIs due under CMS-0057-F. An engineer reviews every piece before it's used.
Where QNXT data goes for CMS-0057-F and claims operations
Into QNXT go enrollment, claims and authorizations. Out of it come the feeds for the FHIR APIs CMS requires, reporting in Snowflake, and Cognizant's agents for routine pended claims, with examiners on the exceptions.
These are working documents, written against your configuration, so your team can run them without us.
report01
DOFR rule review against current delegated contracts
yours to keep
tests02
Regression suite from your claims by line of business
yours to keep
inventory03
QNXT-to-FHIR mapping for the CMS-0057-F APIs with gaps listed
yours to keep
inventory04
EDI partner inventory with format and failure handling per partner
yours to keep
design05
Pilot design for Workflow Agentic Processing with review rules
yours to keep
talent and delivery · trizetto qnxt
Certified engineers, wherever you need them.
Some clients want a project team, some want a couple of engineers on theirs. Either works. Onsite, nearshore or offshore, with handovers across time zones that keep things moving.
Onsite
Engineers at your sites in the US
Nearshore
Overlapping hours with US teams
Offshore
Overnight progress on your backlog
All time zones
Coverage handed over across time zones
24-hour coverage · US Central time
OnsiteUS business hours
Nearshoreoverlapping US hours
Offshoreovernight progress
Combinedhandover, not hand-off
00:0006:0012:0018:0000:00
roles we staff
QNXT benefit and provider configuration analyst
QNXT developer (integrations and extracts)
QNXT claims test analyst
Healthcare EDI developer (834, 837, 835)
FHIR API developer for CMS-0057-F
due diligence · trizetto qnxt
Questions to ask any partner, including us.
Put these to anyone bidding on your TriZetto QNXT work. The ones who've done it answer differently from the ones who've read about it.
Q1
How will you check our DOFR rules against current delegated contracts?
DOFR drift sends claims to the wrong payer. Contract-by-contract tests catch it before recoveries do.
Q2
Which QNXT fields feed each CMS-0057-F API, and where are the gaps?
The APIs are due 1 January 2027. Gaps found late turn into compliance findings.
Q3
Which of our pend reasons are a fit for Workflow Agentic Processing, and how will we know it's working?
Cognizant built it for routine pended claims. The only fair way to judge it is against a baseline for each pend reason.
Q4
How will offshore or vendor staff access member data in QNXT?
Member data access has to follow your contracts and HIPAA policies. Each account needs an owner, and an end date.
Q5
How do you screen QNXT analysts without a public certification?
Cognizant offers no public QNXT certification, so screening has to test the modules and lines of business each person has configured.
01Who hosts QNXT?
Cognizant hosts and manages Facets and QNXT around the clock for many plans. Not every plan runs it that way. We start by documenting how yours is hosted and which parts Cognizant manages.
02Do your people hold a QNXT certification?
Cognizant doesn't run a public QNXT certification. Training goes through TriZetto Learning Services. We screen QNXT analysts by the modules and lines of business they've configured.
03Can you build the CMS-0057-F APIs from QNXT data?
Yes. Impacted payers have to have the Provider Access, Payer-to-Payer and Prior Authorization APIs live by 1 January 2027. We map the QNXT data each one needs and build and test the feeds. Identity controls go in front of the API layer.
04Should we try Workflow Agentic Processing?
That depends on your pend volumes, and on whether examiners work those pends from written procedures. We baseline each pend reason first. Only then do we propose a small pilot, with a human reviewing every denial and exception.
05Do you also work on Facets?
Yes, there's a separate TriZetto Facets page. A lot of the testing, integration and data work carries over between the two.
06Can offshore staff work on QNXT?
Only if your contracts, your Cognizant agreement and your member data rules allow it. We check that before we propose anyone based outside the US.
services
Related services
Projects on TriZetto QNXT usually end up touching one of these, so they're worth a look.
