Healthcare FACETS System

Facets (Trizetto Claims processing system) provides several functionality which is supported under the application group or you can call modules.It helps the organizations to perform their day to day operational work by utilizing any or all of the application groups. Facets is a registered trademark of Trizetto.Facets is a client/server based system ,developed in JAVA technology and all the business rules are running behind the scene as a core functionality.It allows the industry users to be in compliant with all the latest mandates and legislation as long as the latest version of the solution is in place by the Facets users.

Trizetto FACETS Sytem Introduction:

Facets (Trizetto Claims processing system) provides several functionality which is supported under the application group or you can call modules.It helps the organizations to perform their day to day operational work  by utilizing any or all of the application groups. Facets is a registered trademark of  Trizetto.Facets is a client/server based system ,developed in JAVA technology and all the business rules are running behind the scene as a core functionality.It allows the industry users to be in compliant with all the latest mandates and legislation as long as the latest version of the solution is in place by the Facets users.

Facets implementation allows the integration with many 3rd party applications and the most common one is the claims Xten or TPS (Total Payment system). This type of integrations help the organizations to reduce cost and gain high value from the cost saving prospective. Facets have two sides of the jobs in the market which are very demanding.One hand there are less skilled resource available ,but  industry needs more resources to fulfill all the federal/state mandates.

Key Feature:

A Best suited solution of the healthcare management

A Very demanding for handling managed care products

A Very robust and user friendly user interface

Allow great security level with the user roles and access level management

All the application groups are as follows:-

Accounting

Accumulator

Application support

Benefit Configuration

Billing

Hippa Privacy

Capitation

Claims Process

Claims processing-ITS

Commission

Criteria

Customer Service

Dental Plans

Dental provider agreement

FSA Plan

ITS Application Support

ITS Plan

Medical Plan

Provider NetworkX

Provider aggreement

Pricing Profile

Provider

Subscriber

Utilization Management

Workflow Configuration

Note :Each of the Application group is further subdivided into several functionality.

1.  Introduction To Electronic Adjudication

2 Claims Adjudication Flow

  • EDI 837 Inbound Process
  • XC Claims Process
  • XC Database
  • XC Back out Process
  • Multi-Engine Electronic Adjudication Process
  • Batch Action Codes
  • Recall Logic
  • Facets Electronic Claims System Flow

3 Electronic Adjudication Application

  • External Claims Editing Application
  • Electronic Claims Logging
  • FR0400 – Electronic Adjudication – Pended Error Register
  • FR0410 – Electronic Adjudication – Exception Register
  • FR0411 – Electronic Adjudication – Exception Register – Security
  • FR0420 – Electronic Adjudication – Critical Error Register
  • FR0500 – Aged Claims Report
  • FR0597– Error Dental Claim Detail
  • FR0598 – Error Hospital Claim Detail
  • FR0599 – Error Medical Claim Detail

4 Adjudication and Error Messaging

  • System Message Logging
  • Critical vs. Adjudication Errors
  • System Message Data Structure

5 System Administration Consideration

  • Claim Numbering and Auto Numbering
  • Electronic Claims Security

6 Processing 837I

  • Trading Partner Profile
  • Provider Identifier Mapping Logic
  • 837I to XC ITS Host – Provider Host Mapping
  • Recall Logic
  • Inbound 837 Claim Split
  • Manually Splitting Claims
  • Line Item Splits

7 Claim Extract Selection-837P

  • Sorting the extract

8 Outbound Claims File

  • Program
  • Record Types
  • Claim Level Hierarchy
  • Valid Record Types
  • Errors During Pre-processing
  • Pre-processor Actions
  • Outbound Claim Record Sequence
  • Sample Claim in OC File Format
  • Sample Code

9 Outbound Trading Partner

  • INI File
  • Trading Partner
  • Specialty Code
  • Pay To Provider
  • Other Providers

10 Other

  • Translation Error Reporting
  • Claim Extract Status Update
  • Viewing EDI Claims in Claims Inquiry
  • Facets Reports
  • 997 Functional Acknowledgment Summary Report
What is HIPAA Transaction Companion Guides?
The guides can assist vendor or clearinghouse in the set-up and testing process, as well as complying with payer-specific transaction requirements that guarantee smooth and successful EDI transaction responses.
What are the advantages of electronic claim submission?
-Quicker claim submission, which means faster reimbursement to you. -No paper claims to stock and complete. -Simplified record keeping by eliminating lost claims paperwork. -Reduced clerical time and the costs to process and mail paper claims.
How to Submit Electronic Claims?
The Health Insurance Portability and Accountability Act (HIPAA) promotes administrative simplification of claims payment through the use of uniform electronic data interchange (EDI) operations. This includes using standardized code sets, unique health identifiers and measures to keep personal health information secure. HIPAA compliance requires the use of these ANSI ASC X12N (Version 5010) EDI transaction standards.
Is there a way to see sample 837 data?
ISA*00* *00* *ZZ*99999999999 *ZZ*888888888888 *111219*1340*^*00501*000001377*0*T*> GS*HC*99999999999*888888888888*20111219*1340*1377*X*005010X222 ST*837*0001*005010X222 BHT*0019*00*565743*20110523*154959*CH NM1*41*2*SAMPLE INC*****46*496103 PER*IC*EDI DEPT*EM*FEEDBACK@1EDISOURCE.COM*TE*3305551212 NM1*40*2*PPO BLUE*****46*54771 HL*1**20*1 PRV*BI*PXC*333600000X NM1*85*2*EDI SPECIALTY SAMPLE*****XX*123456789 N3*1212 DEPOT DRIVE N4*CHICAGO*IL*606930159 REF*EI*300123456 HL*2*1*22*1 SBR*P********BL NM1*IL*1*CUSTOMER*KAREN****MI*YYX123456789 N3*228 PINEAPPLE CIRCLE N4*CORA*PA*15108 DMG*D8*19630625*M NM1*PR*2*PPO BLUE*****PI*54771 N3*PO BOX 12345 N4*CAMP HILL*PA*17089 HL*3*2*23*0
What is X12 Health Care Claim Transaction Set (837)?
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses.

This course is designed as per the industry best practices. At the end of the course you will be awarded with Elearningline Course Completion certificate for Healthcare.

 

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