Facets Style Benefit Configuration Lab, Plan Build, Claims Simulation, Audit Ledger

Facets Style Benefit Configuration Lab

A training safe, browser only lab that simulates benefit configuration, effective dating, CMS style checks, network rules, claims processing outcomes, testing, change control, and an audit ledger. This is not TriZetto, it is a learning simulator that teaches the same thinking and daily workflow.

1, Plan and Product Setup

This is where you translate Evidence of Coverage, Summary of Benefits, bid details, amendments, and internal standards into a system build.

Line of Business

Plan Code

Product Name

Effective Start Date

Effective End Date

Bid Release Cycle

CMS Style Compliance Checklist

Score, pending

Required, Preventive at zero cost share Required, Out of pocket maximum configured Required, Effective dates align to plan year

Notes, EOC sections referenced

Tip, in a real role you keep traceability, where did this rule come from, what document, what page, what date.

2, Benefits, Accumulators, Authorization Rules

Build benefit tiers, copays, coinsurance, deductible, visit limits, auth rules. The simulator uses these rules to adjudicate claims.

Medical Deductible, Individual

Medical Deductible, Family

Out of Pocket Max, Individual

Benefit Table

Edit, then run claim, then test

Service	Place of Service	Network	Member Cost Share	Auth Required	Visit Limit	Accum Bucket

Member cost share formats supported, COPAY 25, COINS 20%, DED THEN COINS 20%, ZERO. Visit limit example, 12 per year, 1 per day.

3, Network Rules, Provider Constraints, Pricing Impacts

Apply in network, out of network rules, referral, PCP logic, specialty constraints. The simulator uses these rules to route and price a claim.

Referral Required for Specialist

PCP Required to be Assigned

Out of Network Handling

Pricing Model Simulator

Allowed amount, then member share

Contract Discount, In Network

Contract Discount, Out of Network

Allowed Amount Basis

Fee Schedule, Office Visit

Fee Schedule, Specialist

Fee Schedule, Inpatient Day

4, Change Control, Ticketing, Audit Trail

Track requests, maintain audit trail, document why, keep effective dates clean. Every save and test writes to an internal audit ledger with cryptographic hashing.

Change Request ID

Request Type

Owner

Business Summary

Root Cause, if defect

Approval Notes

Claims Adjudication Simulator

Enter claim input, run it, get outcome, paid, denied, pended, with explanation.

Claim Inputs

Professional, Institutional simplified

Member ID

Member has PCP assigned

Referral provided

Service

Place of Service

Network

Provider Specialty

Claim Type

Billed Amount

Units, visits, days

Service Date

Emergency indicator

Simplified learning model. Real claims include diagnosis, revenue codes, modifiers, claim edits, coordination of benefits, and many more steps.

Outcome

Pending

Run a claim to see paid, denied, pended, with a trace explaining which config rule was used.

Allowed

Based on fee schedule or billed minus discount.

Member Pays

Copay, coinsurance, deductible, out of network rule.

Plan Pays

Allowed minus member responsibility.

Testing, Regression, Root Cause

Compare expected to actual

Regression Test Results Configuration vs Data vs Code

In real operations, you gather claim samples, reproduce in test, verify member, provider, network, edits, and effective dates.

Integrations, EDI, Eligibility, Enrollment

Conceptual only

Eligibility 270 request, simplified

Claim 837 stub, simplified

This section helps students connect Facets configuration to upstream, eligibility and enrollment, and downstream claims reporting.

Echolink Solutions Lab, Benefit Build, Claims Logic, Change Control, Audit Ledger