Processing a Dental Claim in Facets

In response to MD Harun Rashid's request, I am again giving an example of Dental Claim which is similar to Real Life Scenario. The test case name is Oral Surgery. These are the steps that you are supposed to perform to process a dental claim in Facets under medical plan.

Step 1: Open Test Lab Module of ALM, you will see the following test case in test lab module of ALM/QC.

Test Case description: Process a claim for Oral Surgery services using following data: INN Provider 333444555777 (Dental Surgeon), POS 11, HCPCS D7240, Subscriber ID-100200300, Diagnosis code ICD10:  k08499, Charges (PCP's Fee) $350, Unit 1(One Time Visit).

Expected Result: Claim should apply a Copayment of $50 , then process at 80% of the allowable.

Step 2: Open Facets Claims Processing application group and scroll down to Dental Claims processing application.

Step 3: In the Indicative page of Medical Claims processing application, enter the following data: Subscriber ID and select a member from the drop down menu, Claim Received Date(suppose Jan 25, 2017), Provider ID and Diagnosis code.

Step 4: Now double click on Line Item page and when you are in Line Item page, enter the following data: Date of service (suppose Jan 20, 2017), POS, HCPCS code, Charges(suppose $350), Unit(suppose 1), Total charges(Suppose $350).

Step 5: Press F3 on your keyboard to process the claim. Now check the claim pricing.

Step 6: If the claim applies a copayment of $50 as expected and then process at 80% of the allowable, save the claim by pressing F4 on your keyboard. Facets will generate a claim ID automatically. Suppose the claim ID is 000011112222

Step7: Open Lab module of ALM, take required screenshots and type as follows in actual result edit box:

Claim processed as expected and write the claim ID and pass the test case.

Note: HCPCS stands for Healthcare Common Procedure Coding System.

Processing a Medical Claim in Facets

One of the visitors of this site named MD Harun Rashid wanted to know how to process a medical claim in Facets. So, I am narrating below what are the steps one is supposed to perform to process a medical claim in Facets.

Step 1: Open Test Lab Module of ALM. Suppose the test case is PCP Office Visit.

Test Case description: Process an office visit  professional claim using following data:

PCP ID 111222333444 (Family Practice), POS 11, CPT code 99214, Subscriber ID-111222333, Diagnosis code-ICD10:  E11618, Charges(PCP's Fee)-$100, Unit 1(One Time Visit).

Expected Result: Claim should apply a Copayment of $35 , then process at 100% of the allowable

Step 2: Open Facets Claims Processing application group and scroll down to Medical Claim processing application.

Step 3: In the Indicative page of Medical Claim processing application, enter the following data: Subscriber ID and select a member from the drop down menu, Claim Received Date(suppose Jan 25, 2017), Provider ID and Diagnosis code.

Step 4: Now double click on Line Item page and when you are in Line Item page, enter the following data: Date of service (suppose Jan 20, 2017), POS, CPT code, Charges(suppose $100), Unit(suppose 1), Total charges(Suppose $100).

Step 5: Press F3 on your keyboard to process the claim. Now check the claim pricing.

Step 6: If the claim applies a copay of $35 as expected and then process at 100% of the allowable, save the claim by pressing F4 on your keyboard. Facets will generate a claim ID automatically.

Step7: Open Lab module of ALM and type as follows in actual result edit box:

Claim processed as expected and write the claim ID and pass the test case.

Back End Validation of Pre-existing conditions in Facets

As per  Affordable Care Act (ACA) popularly known as Obamacare, no NGF health plan can apply pre-existing conditions from 2014. This is one of the popular and major pillars of ACA. President Donald Trump and Republicans want to repeal and replace ACA but they all like the pre-existing conditions related provision of the ACA. So, we do hope , if Obamacare is repealed and replaced, still the pre-existing condition policy of the ACA  will will be incorporated in  the Replacement Act in some form. So, developers, configuration analysts, quality assurance analysts and testers has a great role to implement this provision of the law.

Facets application is a great tool to handle pre-existing condition policy. In my previous post, I have narrated how to validate whether the health plan of a group has excluded pre-existing condition or not. It was Facets front end validation. Now let us discuss how to perform  Facets back end validation. In order to perform this validation, you need the product id of the particular health plan and access to the database .

Step 1: Open Facets Medical Plan application group and scroll down to Product application.

Step 2: Now press Ctrl+O on the keyboard and enter product Id in edit box and click OK. you will find the different information of the products on the right hand site of the window.

Step 3: Double click on "Components" section and Facets will display you all the product component prefixes of the product. Note 4 digit (alphanumeric) Administrative Information prefix id . Suppose it is A001

Step 4: Now open your database and open the  Administrative Information table of the database.

Step 5: Now run a query using Administrative Information prefix id.

Now check the pre-existing months column of the query result. You will see here 0 months if there is no pre-existing condition in the particular health plan.

President Donald Trump Signed an Executive Order

President Donald Trump took initiatives to dismantle Obamacare by signing an executive order on January 20, 2017. With his signature, Trump sent a powerful signal on the first day of his presidency that his top priority in the Oval Office would be dismantling the  Affordable Care Act popularly known as Obamacare.

The multi-part executive order stated that the administration's official policy is "to seek the prompt repeal" of the Affordable Care Act but at the same time emphasized that it must continue to uphold the law. The order did not change the law, but could have a significant impact nonetheless.

It directs the secretary of health and human services, as well as other agencies, to interpret regulations as loosely as allowed to minimize the financial burden on individuals, insurers, health care providers and others.

It stressed that agencies can "waive, defer, grant exemptions from or delay implementation of any provision or requirement" of Obamacare that imposes a burden "to the maximum extent permitted by law."

One possible example is the individual mandate, which requires most Americans to be insured or pay a penalty unless they can prove a financial hardship. The Trump administration could try to loosen the criteria for qualifying for a hardship exemption. That way, fewer people would have to pay the penalty, which would be in line with the executive order and the call to provide relief to Americans suffering from the Obamacare's high costs.

In keeping with longstanding Republican beliefs, the order also looks to give states more flexibility and control over their health care markets and to allow insurers to offer policies across state lines.

All of these actions will start to shift the nation's health care rules toward Republican ideas. And it will allow the Trump administration to chip away at the law going forward.

It may mentioned that much of Obamacare has already been set in regulation, which a president does not have the power to nullify and which can take months or even a year or two to change.

Creating a Pended Claim in Facets

When we create a claim in Claims processing application in Facets and hit F3 to process  it, facets sometimes gives us error message instead of processing the claim. The reason may be facets internal issue or any input data that we have entered while creating  a claim.

In order to log a defect and reproduce the error message in future, we create a Pended claim in Facets Claims Processing application.  Here are the steps that we perform in Facets to create a pended claim.

Step1: Press F5 on your keyboard , you will see the Next Review Date window.

Step2:  Click OK , you will see the Explanation window.

Step3: Select “5000” under  Code column. When “5000” code will be selected OK button will be enabled.

Step4: Now click on OK button. Facets will generate a 12 digit claim ID automatically. Store it in ALM Lab section .

Let us think in this case, the pended claim ID generated by Facets is 000000000001

Step5: Now press Ctrl+ O, the  Open window will be opened:

Step6: Next enter 12 digit claim id in Claim ID edit box.

Step7: Click on OK button and check the Claim. You have to review that the claim is the same as before and there is still error message.

Step8: To be more sure, press F3 to process the claim again. If the page looks as before, take screenshots and log a defect in ALM/QC.

The developer/configuration analyst will take care of the defect, when defect fixed, you will retest the claim. If it passes , that is, there is no more error message in facets and the claim processed as per the test case, save the claim. Now it will be a regular claim. And close the defect in ALM/QC.

How to Login Facets System?

Facets login means you are going to connect to some SQL Server. It depends on user's role in the company.  Security system is very very strong. So, unauthorized user can never ever login to Facets application.

Generally, you will see Facets icon on your desktop. Most of the time , Facets is housed in Virtual Desktop. Double click on the Facets icon on your desktop, it will direct you what to do next. Let us suppose we want to login "Facets Medical Claims Processing + ITS" application in Testing Environment. Here Testing Environment means front end facets will be connected with"testing environment Server Name_SIT_facets.pzb".

When users will work in Facets in this environment, all data will come from this database and if user saves any data , the data will be stored in this database. When users  process a claim and save it by pressing F4 button, facets will generate a claim ID automatically and claim id will be stored in this database. Later on, anybody can open that claim and review.

Sometimes , your company will give you user name and password to login facets as per your role in the company.

For Back End login, you must have access to the company's database. It varies company to company. Actually, for back end login, you will login to some version of SQL server. Facets is housed in SQL Server. If company grants you access to their database, you can access to database without any user name and password.

Some company may give you user name and password to access their database.

How to make a comment in this blog site?

It is a little bit tricky to make a comment for the first time visitor. Here are the steps you are supposed to perform to make a comment.

Step 1: Open my blog site and select a topic such as-Pre-Existing Conditions in Future US Healthcare Act

Step 2: Scroll down to "Post a Comment" and type your comment (such as I agree 100% with the blogger that there should not be any pre-existing conditions in any  healthcare insurance plan in USA).

Step 3: Scroll  down to "Comment as:" and click on Triangle icon(dropdown menu) on the right of  "Select Profile" edit box

Step 4: Select "Google  Account" from the drop down menu of "Select Profile" edit box and click of "Publish". System will direct you to your Google Account.

Step 5: Now login your google account using your user name and password 

Step 6: When you are in your account, click on "Publish"

Step 7: Check Google  message , if Google says , your comment is published, it is done!! 

But if Google says something else, it means you have missed any something.

Note: If you want to learn more on any specific healthcare topic / Facets application, please write your requirement  specifically with your email address. I will get back to you as soon as possible.

Obamacare Replacement Act

Kentucky Sen. Rand Paul on Sunday(Jan 15, 2017)  unveiled the broad outlines of his Obamacare replacement package. Main features of the package will be published when they will be available. 

If Republicans want to repeal and replace Obamacare with better option , they have to first ensure good features of Obamacare.

Before Obamacare, insurance companies had ways  of making certain patients pay more. one of the ways was to enact lifetime cap. It means Insurance companies would cover healthcare costs to a certain point, but once a patient with a serious chronic disease hit the lifetime limit, he was maxed out for ever. There are many people who need expensive medical care for their entire life. To them, lifetime coverage cap was surrendering themselves to death. For them, Obamacare was  a great blessing.  Under Obamacare, insurance companies are not allowed to apply lifetime coverage provision.

Pre-Existing Conditions in Future US Healthcare Act

During election campaign, US President-elect Donald J Trump promised that he would repeal and replace Obamacare. After winning election, he has iterated his promise. He is scheduled to take office as the 45th President on January 20, 2017. So, it is for sure he would take prompt steps to repeal the Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) and nicknamed Obamacare.

Republican dominated Congress has already started the process. U.S. House Republicans on Friday (Jan 13,2017) won passage of a measure starting the process of dismantling Obamacare. The House of Representatives voted 227-198 to instruct committees to draft legislation by a target date of Jan, 27 that would repeal the 2010 Affordable Health Care Act. Ten members didn't vote.

US patients await Obamacare's fate "By taking the first step toward repealing Obamacare, we are closer to giving  Americans relief from the problems this law has caused," House Speaker Paul Ryan said in a statement following the vote. "This resolution gives us the tools we need for a step-by-step approach to fix these problems and put Americans back in control of their health care."

The Senate approved the same measure by 51-48 on Thursday(Jan 12,2017).

A group of nine moderate and conservative House Republicans voted against the bill with concerns that Republicans would end up repealing the law without clearly laying out and presenting their replacement.

"The only thing I've ever asked for is that the replacement plan be fully developed before we take on the repeal issue," Rep. Charlie Dent, R-Pennsylvania, a leading moderate who voted against the measure, said in an interview.

“I want to make [sure] people who have pre-existing conditions don’t get frozen out of the market,” Tom MacArthur, R-New Jersey, said after voting against the resolution. “I am getting a lot of calls. People are concerned about fixing health care. They are much more concerned about the substance of the fix than the timing of the fix.”

If ACA is repealed, 20 million Americans will be affected. But it is extremely unlikely that they will lose coverage this year. If those who get their health insurance through work or Medicare, the repeal legislation alone will have minimal effects on their coverage, even in the long run.

Democrats may make the argument that Republicans cannot realistically “repeal” parts of the law without excluding popular provisions like protections for people with pre-existing conditions.

“Here is the problem that they have,” Congresswomen Jan Schakowsky, D-Illinois, said during a press conference  with Democratic House members. “All of the parts are like a puzzle that was carefully crafted and put together and you take a piece out and it no longer works. And that is what they are coming to realize. They have had six years to come up with something and they have come up with exactly nothing."

Whatever happens,  let them happen. I request the visitors of this site to tell something about the major pillar of ACA , that is , repealing of Pre-Existing Conditions. Let us urge all whatever be the future US Healthcare Law, it should have this pillar of Obamacare. President-elect Donald Trump also likes this provision of Obamacare.

Stop Ages/Waiting Periods Application in Facets

Facets Medical Plan application group has a application called the Stop Ages/Waiting Periods application. 

This application allows configuration analysts or developers  to create product eligibility rules for the subscriber, spouse, dependents and students within a group. They can create records identifying the waiting period before plan coverage begins, and the ages at which benefits coverage stops. Each record that they define in this application can then be linked to a class/plan in the Class/Plan Definition application of the Medical Plan application group . A class/plan record cannot be saved unless a Stop Ages/Waiting Periods rule has been attached to it.

Pre-Existing Conditions Application in Facets

Facets Medical Plan application group has an application called Pre-Existing Conditions application.

The Pre-Existing Conditions application allows you to establish diagnosis codes that might indicate conditions that existed before a member joined specific Health Plan. When a line item with one of the diagnosis codes listed in this application is processed for the member for either claims or Utilization Management or Pre-Authorizations or referrals, and the service date falls within the period indicated on the Administrative Information application, Facets displays the warning message, Possible Pre-Existing Condition.

Validating Pre-Existing Conditions in Facets

It is one of the most important requirements for a Non-Grandfathered health Pan to validate that it has no Pre-Existing conditions after ACA comes into force. The test case should be like this or similar:

Validate that the existing conditions have been removed from the heath plan of the group.

In Facets, every health plan has four major components. They are Group Id, Product Id, Plan ID and BSBS prefix. In Facets, there is an application group named Medical Plan. This application group has many applications  and one of the applications is BSBS. So in order to validate that the health plan has no pre-existing conditions, we have to perform following steps: 

Step1: Open Facets and scroll down to Medical Plan application group.

Step2: Open the applications of the  Medical Plan application group

Step3: Scroll down to BSBS application and press Ctrl+O to open BSBS window.

Step4: Now enter BSBS prefix in BSBS window edit box and click OK.

Step5: Now Scroll down to PREX(PRE-EXISTING WAITING PERIOD) and click on it.

Now facets will show you whether the plan has pre-existing conditions or not. If the Health Plan has no pre-existing conditions, Facets will display the following information:

No Pre-existing Waiting Period is applicable

This is how Pre-existing conditions are validated using Facets.

ObamaCare & Pre-existing Conditions

A pre-existing condition is a medical condition that is excluded from coverage by an insurance company. It means a medical condition that started before a person's health insurance goes into effect.  Because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company. Unless ObamaCare comes into force, that is, before 2014 some insurance policies would not cover expenses due to pre-existing conditions.

Affordable Care Act  popularly known as ObamaCare eliminates pre-existing conditions starting 2014. Under the Affordable Care Act, health insurance companies can’t refuse to cover a subscriber or charge him more just because he has a “pre-existing condition”, that is, a health problem he had before the date that new health coverage starts. They also can’t charge women more than men. These rules went into effect for plan years beginning on or after January 1, 2014.

No more pre-existing conditions means that health insurance companies can no longer charge more or deny coverage to subscribers or their children because of a pre-existing health condition like asthma, diabetes, or cancer. Health insurance companies cannot limit benefits for that condition either. Once a person has insurance, they can't refuse to cover treatment for his pre-existing condition.

Being sick or having been sick in the past can no longer can keep health insurance participant from coverage. Considering 1 in 2 Americans has a health condition that qualifies as a pre-existing condition, doing away with pre-existing conditions is a big deal for those people.

One Exception: Grandfathered Plans

The pre-existing coverage rule does not apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is a policy that customers bought for  or thekselves of for their family on or before March 23, 2010 that has not been changed in certain specific ways that reduce benefits or increase costs to consumers.

Pre-Existing Condition Insurance Plan (PCIP) Coverage

The Pre-existing Condition Insurance Plan (PCIP) ended on April 30, 2014.  The PCIP program provided health coverage options to individuals who were uninsured for at least six months, had a pre-existing condition, and had been denied coverage (or offered insurance without coverage of the pre-existing condition) by a private insurance company. Now, thanks to the Affordable Care Act, health insurance plans can no longer deny anyone coverage for their pre-existing condition, and so PCIP enrollees can transition to a new plan outside of the PCIP program.  

Medical Provider Agreement application group in Facets

The applications of the Medical Provider Agreement application group is used to establish or edit an agreement between participating providers and Health Care Payers. The applications in the Medical Provider Agreement application group are:

1. Agreement, Medical

2. Auto Room Type

3. DRG Rules

4. Exclusions

5. Procedures

6. Prompt Payment Discount

7. Stoploss

Outpatient Care and Facets

All health care services can be broadly divided as two major categories- Outpatient Care and Inpatient Care.

The care a patient receives without being admitted to a hospital, such as at a doctor's office, clinic or same-day surgery center is known as Outpatient Care. Home health services and hospice care are also included in this category. Some plans may limit coverage to no more than 45 days.

Who is an outpatient?

Ø  An outpatient  is a patient who is not hospitalized overnight but who visits a hospital, clinic, or associated facility for diagnosis or treatment. An outpatient is a patient who is hospitalized for less than 24 hours.

Ø  A patient is an outpatient if he is  getting emergency department services, observation services, outpatient surgery, lab tests, or X-rays, or any other hospital services, and the doctor hasn't written an order to admit him to a hospital as an inpatient. In these cases, he is  an outpatient even if he spends the night in the hospital.

Ø  A patient is any recipient of health care services. The patient is most often ill or injured and in need of treatment by a advanced practice registered nurse, physiotherapist, physician, physician assistant, psychologist, podiatrist, veterinarian, or other health care provider.

Facets uses different codes for places of treatments(POT). POT for  Outpatient Care depends on  from what type of provider the patient is receiving medical services/treatments. As applications of Facets can be configured as per health care payers' requirements, codes for POT/POS may be different. I am giving below some typical POT/POS  codes for Outpatient Care.

POT/POS  Codes	Meaning
01	Pharmacy
11	Office
12	Patient’s Home
17	Retail Health Clinic
20	Urgent Care Facility
22	Outpatient Hospital
23	Emergency Room–Hospital
31	Skilled Nursing Facility
52	Psychiatric Facility Partial Hospitalization
65	End Stage Renal Disease Treatment Facility
72	Rural Health Clinic
81	Independent Laboratory