Dashboard – Your Mini Payer
This app simulates a simplified Facets/TriZetto environment. Everything here is local in the browser: no real PHI, no server. Use it as a lab to practice configuration and claims logic.
Recommended Exercise Flow
- Create at least one payer and one plan with deductible and coinsurance.
- Add at least two providers (one in-network, one out-of-network).
- Add at least two members and assign them to a plan.
- Create and adjudicate several claims with different scenarios:
- in-network vs out-of-network providers
- with and without prior authorization
- members at different deductible usage
- Run a billing cycle and examine monthly premiums per payer.
- Review reports (total members, claims, paid vs denied, total paid).
Payers & Groups
Define payer organizations or groups (e.g., “Echolink Health Plan”, “City of Dallas Group Plan”) and later attach plans to these payers.
New Payer
Payer / Group List
| ID | Name | Code | Region | Type | Plans |
|---|
Members & Enrollment
Configure members, assign plans, and track deductible usage. This simulates enrollment & eligibility in Facets.
Create Member
Member List
| ID | Name | DOB | Plan | Eff Date | Term Date | Deductible Used |
|---|
Providers & Contracts
Create providers, mark them as in-network or out-of-network, and assign a contract rate modifier.
New Provider
Provider List
| ID | Name | Specialty | NPI | Network | Contract Rate |
|---|
Plans & Benefits
Define simple plans with monthly premium, deductible, coinsurance, and prior authorization rules. Each plan is attached to a payer.
New Plan
Plan List
| ID | Name | Payer | Premium | Deductible | Coinsurance | Requires Auth |
|---|
Claims & Adjudication
Create claims for members and providers, then run simplified adjudication logic: eligibility check, network status, contract rate, deductible, coinsurance, and authorization.
New Claim
Claim List
| ID | Member | Provider | Date | Service | Status | Plan Paid | Member Pays | Reason |
|---|
Billing & Premiums
Generate simple premium invoices per member for a selected month, using their plan’s monthly premium and payer.
Billing Cycle
Generated Premiums (Per Member)
| Month | Member | Member ID | Payer | Plan | Premium |
|---|
Reporting & Analytics
View simple operational metrics: total payers, members, providers, claims, paid vs denied, and total plan paid.
How This Lab Maps to Your Facets Curriculum
Use this mini payer simulator alongside your lectures. It is not TriZetto software, but it models the same ideas: payers, members, providers, plans, claims, billing, and reporting.
Modules & Where to Practice
- Module 1 – Intro to Healthcare & Facets: Use the Dashboard and talk through the ecosystem.
- Module 2 – Payers & Groups:
Payers & Groupstab – define payers, employer groups. - Module 3 – Member & Enrollment:
Members & Enrollmenttab – create members, coverage spans, deductible usage. - Module 4 – Provider & Network:
Providers & Contractstab – in-network vs out-of-network, rate modifiers. - Module 5 – Benefits, Pricing & Adjudication:
Plans & Benefits+Claimstabs – deductibles, coinsurance, prior auth. - Module 6 – Claims Processing & Edits:
Claimstab – denied vs paid vs partial, reasons. - Module 7 – UM & Authorization: Use the “Requires Auth” plan option and claim auth flag.
- Module 8 – Billing & Premiums:
Billingtab – generate monthly premiums for members by payer. - Module 9 – Reporting & Analytics:
Reportstab – total claims, paid amount, denial rate. - Module 10 – Compliance & Governance: Discuss how each configuration choice impacts money, fairness, and auditability.
Core Components of Facets Configuration
- Claims Processing: Adjudication rules, payment schedules, and denial management. In real Facets, this includes benefit application, clinical & coding edits, and generating 835 remittance data.
- Member Management: Eligibility verification, enrollment workflows, and demographic updates. Think enrollment feeds (e.g., 834), coverage spans, and member ID cards.
- Provider Network Management: Contracts, fee schedules, and reimbursement setup. This is where in-network vs out-of-network, reimbursement tiers, and NetworX pricing rules map back to real money.
- Financial & Billing Operations: Premium billing, capitation/risk allocation, and accounting. Facets ties group bills, capitation payments, and ledger entries into one financial engine.
- Utilization Management: Monitoring of authorizations and care coordination. Prior auth decisions feed directly into claims payment and medical management reporting.
- System & Data Configuration: Workflow engines, rule editors, reporting, and dashboard customization. This is where Facets administrators tune the system without changing core code.
Key Functional Modules & Technical Aspects
- Configuration Tools: Used to map business rules and customize interfaces. In Facets this means product/benefit builders, provider contract screens, and table-driven configuration instead of hard-coded logic.
- EDI Processing: Configuration for HIPAA transactions like 834, 835, 837, 270/271, 276/277. These drive enrollment, claims submission, eligibility checks, remittance, and claim status.
- NetworX Suite: Integrated tools for pricing, modeling, and bundling administration. NetworX enforces payment policies (e.g., bundling, multiple procedure logic) before the claim posts financials.
- Integration: Real-time and batch data exchange, including PBM and third-party interfaces (care management, CRM, provider portals). In real Facets, this is often a mix of EDI, web services, and file feeds.
- Compliance: Updates for Medicare/Medicaid standards and state regulations. Configuration must keep up with CMS rules, benefit mandates, and state filing requirements—without breaking existing claims.
- Reporting & Analytics: Operational and regulatory reporting (encounters, HEDIS, risk scores) built on Facets data, used by actuaries, compliance teams, and leadership.
As you use this mini payer, you can point out: “This field maps to Claims Processing, that tab maps to Member Management, these tables mimic EDI Processing, and so on. It gives students a mental model of how TriZetto Facets is wired under the hood.
Mini Payer Scenario
- Create:
- Two payers and at least two plans
- Five providers (PCP, Specialist, Hospital, Telehealth, Urgent Care)
- Three members (with different plans)
- Submit at least five claims with different combinations: in-network/out-of-network, with/without auth, different charges.
- Generate premiums for one month.
- Screenshot or export:
- Payers table
- Members table
- Providers table
- Plans table
- Claims table
- Billing table
- Reports metrics
- Write a 1–2 page reflection: “What configuration decisions impacted payments the most?”