Healthcare & Facets Configuration – labs.echolinksolutions.com

Module 1 Intro to Healthcare & Facets

Module 1 – Introduction to Healthcare & Facets

Goal: Understand what Facets is, where it fits in the U.S. healthcare ecosystem, and how members move from enrollment → claims → payment.

Concept Check

1. Payers vs Providers vs TPAs

For each scenario, select whether it describes a Payer, Provider, or TPA.

Scenario 1: Processes claims, applies benefits, and pays providers.

Scenario 2: Sees the patient, performs surgery, and submits claims.

Scenario 3: An employer self-funds insurance and hires a company to administer claims.

Scenario 4: Runs a hospital and bills for inpatient stays.

Facets Components

2. Where does each activity live in Facets?

Map each real-world activity to the Facets area that primarily supports it.

Generate monthly invoices for an employer group.

Check if a member is eligible on the date of service.

Apply contract rates for an in-network cardiologist.

Explain to a member why a claim was denied.

Mini Lab

3. Member Journey – From Enrollment → Claim Payment

Arrange the steps in the correct order for a typical member journey in a Facets-driven health plan.

A. Provider submits claim B. Facets processes & adjudicates claim C. Member receives ID card & coverage D. Member enrolls in plan E. Plan bills employer for premiums F. Member visits provider G. Payment & EOB are generated

Enter the correct order using letters (e.g., D, C, F, A, B, G, E):

Short explanation (optional):

Roles

4. Roles: BA vs Configurator vs Developer

For each task, choose which role is primarily responsible. (In real projects they collaborate.)

Document new benefit rules for a 2026 Gold Plan.

Configure deductibles and copays inside Facets.

Build an API that sends claim status to a provider portal.

Module 2 Environment & Navigation

Module 2 – Environment & Navigation

Goal: Understand the Facets interface, environments (Dev/QA/Prod), and basic data model concepts.

Lab – Explore the Facets Environment

Log in to the Dev or Training Facets environment provided by your instructor.
Identify the main menu areas that match: Members, Providers, Claims, Billing, Authorization.
Take note of:
- where search screens are located
- where configuration vs operational screens are located
Locate where you can:
- view a member record
- view a provider record
- open a claim
Write down the differences between:
- Dev – safe to experiment
- QA – used for testing
- Prod – real members & real money

Deliverable: A one-page screenshot or summary of key Facets navigation areas and what they are used for.

Reflection Questions

Why is it dangerous to configure directly in Production?
How do security roles protect PHI and payments?
Where do you think “configuration vs customization” shows up in the UI?

Module 3 Member & Enrollment

Module 3 – Member & Enrollment Configuration

Goal: Configure a member, coverage, and understand eligibility rules.

Lab – Configure a New Member

Create a new member using test data (no real PHI). Include:
- First/Last Name
- Date of Birth
- Member ID (training format)
- Address
Assign the member to:
- an employer group
- a product / plan
Configure coverage dates (effective and end date).
Add at least one dependent (spouse or child) and link them to the primary member.
Review how eligibility will appear to the Claims module.

Deliverable: Screenshot or documentation of the member + dependent + coverage configuration, with explanation of eligibility rules.

Extension – Coverage Tiers & Retro Changes

Simulate a “Single → Family” tier change mid-year and note what happens to coverage dates.
Simulate a retro termination and predict impact on claims already paid.

Module 4 Provider & Network

Module 4 – Provider & Network Configuration

Goal: Set up a provider, assign network and contracts, and understand impact on pricing.

Lab – Create a Provider & Assign to Network

Create a new provider record with:
- Provider Name
- NPI (test format)
- Tax ID
- Specialty (e.g., Cardiology)
Assign the provider to:
- at least one network (e.g., Commercial PPO Network)
- a primary location
Link the provider to a simple contract / fee schedule.
Document how the contract rate will affect claim pricing.

Deliverable: Provider profile screenshot + explanation of network and contract impact.

Module 5 Benefits & Adjudication

Module 5 – Benefits, Pricing & Adjudication Rules

Goal: Configure a simple benefit plan with deductible and copay, and understand how Facets uses it.

Lab – Configure a Sample Benefit Plan

Define a Product (e.g., “2026 Silver PPO”).
Create a Benefit structure for:
- Primary Care Visits
- Specialist Visits
- Emergency Room
Set:
- Annual Deductible (e.g., $1,000)
- Office Visit Copay (e.g., $30 PCP, $50 Specialist)
- Coinsurance after deductible (e.g., 20%)
Attach the benefit plan to a test member or product group.
Predict how a $200 specialist visit will adjudicate under these rules.

Deliverable: Benefit configuration summary + a worked example of a claim using your plan.

Module 6 Claims & Edits

Module 6 – Claims Processing & Edits

Goal: Walk a claim through the lifecycle and understand edits & denials.

Lab – Process a Claim & Review Edits

Using your test member, provider, and benefit plan, create a sample claim (or use provided test claim).
Submit the claim in the training environment.
Observe:
- front-end edits (missing data, invalid codes)
- back-end edits (benefit rules, duplicate checks)
Document:
- Claim status (paid, denied, pended)
- Denial or adjustment codes
- Member vs plan responsibility
If there is a denial, propose a configuration fix or business explanation.

Deliverable: Claim lifecycle summary and at least one denial example with root cause.

Module 7 UM & Authorizations

Module 7 – Utilization Management & Authorizations

Goal: Configure a simple prior authorization rule and see how it interacts with claims.

Lab – Configure a Prior Authorization Rule

Choose a high-cost service (e.g., MRI of knee).
Create an authorization rule that requires prior approval unless emergency.
Enter a sample authorization request and approve it.
Submit:
- Claim that has an approved auth
- Claim that does not have an auth
Compare outcomes and document what Facets did differently.

Deliverable: Short write-up of how authorizations affect claims, with screenshots/notes.

Module 8 Billing & Premiums

Module 8 – Billing & Premiums

Goal: Set up a simple employer billing scenario and understand invoicing and payments.

Lab – Create Billing Setup for Employer Group

Select or create an employer group (e.g., “TechCo Inc.”).
Define monthly premium rates (e.g., Employee Only, Employee + Spouse, Family).
Run a test billing cycle and generate an invoice for the group.
Post a payment (full or partial) and note:
- how the system records balance due
- what happens on the next billing cycle

Deliverable: Copy of a sample invoice and explanation of how it ties to eligibility.

Module 9 Reporting & Analytics

Module 9 – Reporting & Analytics

Goal: Run basic operational reports (eligibility & claims performance) and interpret them.

Lab – Run Eligibility & Claims Reports

Locate the standard reporting module or extracts in your Facets training environment.
Run:
- Eligibility report for a specific group or line of business
- Claims performance report for a given month
Identify at least:
- total members
- total claims
- paid vs denied claims ratio
Write a brief interpretation of what the data suggests.

Deliverable: Simple 1–2 paragraph summary of eligibility & claims metrics.

Module 10 Compliance & Governance

Module 10 – Compliance, Security & Governance

Goal: Connect Facets configuration to HIPAA, CMS, audit logs, and change management.

Lab – Compliance & Change Management Walkthrough

Identify at least 3 examples of PHI in Facets (e.g., member name, DOB, claim details).
Review where audit logs or history are visible in the UI (e.g., who changed what & when).
Describe how a configuration change should move through:
- Request → Design → Build → Test → Approval → Deploy
Discuss what could go wrong if:
- changes skip testing
- security roles are too open
- audit logs are not monitored

Deliverable: A short “governance checklist” for safe Facets configuration.

Capstone Mini Payer

Capstone Project – Build a Mini Payer

Goal: Use everything from Modules 1–10 to configure a small but realistic “mini-payer” in Facets.

Capstone – Configuration Blueprint

Define your scenario: Choose a line of business (e.g., Commercial PPO for 1 employer group).
Create Members: At least:
- 2 primary members
- 2–3 dependents
Build Provider Network:
- Primary care provider
- Specialist
- Hospital
Configure Benefits:
- Deductible, copay, coinsurance
- At least one prior auth rule
Process Claims:
- Office visit
- Specialist consultation
- One service that requires prior auth
Generate Reports:
- Eligibility snapshot
- Claims summary
Risk & Governance: Document at least 3 risks and how you would mitigate them.

Final Deliverable: Presentation or document walking through your mini payer, with screenshots and configuration decisions.