Facets – Quick Reference
Steps to add a Member in Facets:
1. File/New in the Subscriber/Family application
2. Enter the Group ID (i.e. TXMCD000)
3. Enter the Subgroup assignment (County) by searching by the Group ID
4. Class Subsection – (i.e. CD03)
5. Eligibility subsection – Edit Add
Initial entry is always a Select event – Family Indicator – Subscriber Only
Ensure your effective dates match
Select a Plan ID
6. Eligibility subsection – ensure the eligibility line was added
7. * PCPs are added under the Member subsection within the PCP tab (Edit-Add-Subsection
and enter Provider ID)
Steps to add a Provider in Facets:
1. If adding a Practitioner you must first create a Common Practitioner record – File/New
2. Practitioner Section – File/New and enter the Common Practitioner ID
3. Address subsection, Tax Information Subsection and Payment Information subsection are
required
4. Save the record
Steps to add a PCP to a Member:
1. Under Subscriber/Member go to Subscriber/Family and select Member section
2. Select the PCP tab
3. Edit/Add/Subsection
4. Enter Practioner ID (PCP ID)
5. Note – The PCP you are adding needs to have YES row consistent with the Members’
Product
4 Reasons to create a TOS:
1. Benefits
2. Pricing
3. Authorizations
4. Reporting
List the 6 TOS Tables in Facets:
1. TPCT – Procedure Conversion Table
2. RCCT – Revenue Conversion Table
3. SECT – Service Conversion Table
4. SRCT – Supplemental Revenue Conversion Table
5. SPCT – Supplemental Procedure Conversion Table
6. SEDS – Service Description Table
Steps to Create a Type of Service (TOS, Service ID)
1. Add entry to the SEDS (Service ID Description table)
2. Add entry to the SECT – this table is an exact duplicate of the SEDS table
3. Map the TOS:
Is it a Revenue Code? Enter in the RCCT (Revenue Code Conversion Table)
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Facets – Quick Reference
Is it a Procedure Code? Enter in the TPCT (Procedure Code Conversion table)
Prefix 0001 – Texas (Global) alpha/numeric
Prefix 0002 – SNP numeric
How does the system know to supplementally map a TOS? It goes to the SPCT and SRCT
prefix on the Member’s product component record
What criteria is used to create a preliminary or base TOS:
Category
Setting
Procedure
What criteria is used to create a supplemental TOS?
Diagnosis Age
Modifier Related Diagnosis
Place of Service Procedure
What are the 4 Provider Types in Facets?
1. Practitioner 3. IPA
2. Group 4. Facility
When adding a Practioner record what must first be entered and what information does that
entry store? A common practitioner record, and this entry stores data that will not change (i.e.
social security, license numbers,DOB, etc…)
What are the required fields to load a Practitioner?
Indicative Section Tax Information
Address Payment Information
Describe the Claims to UM Match Process:
Looks at member Eligibility first – is there a valid eligibility row in a valid Plan and
Product – then proceeds:
1. Is the service rendered on the claim on the IPMC listing – this is a product component on
the member record – If yes it requires an authorization
2. System continues to create the TOS
3. Does the TOS require an authorization based on the SEDF from the Agreement
4. If no Agreement is matched then it defaults to the product on the SEDF on the component
member record
5. Is the SEDF checked to ignore the CLUM and match on Procedure code, Place of Service
User Messages vs. System Messages:
> or 149 = User Message
<149= System Message
What important information is stored in the Class Plan Information?
1. Network Set
2. Covering Provider Set
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What explanation system codes within Facets are not to be used?
Those codes that begin with the letters C D P N U T S
What are the 23 Product Components and describe each?
1. ACIN – Claim Interest Rates
2. AIAI – Administrative Information, stores claims processing parameters, PCP
required, claim accept months, drag provisions, same day surgery,
3. ARAR – Administrative Rules for UM
4. BSBS – Benefit Summary
5. CBCB – COB Rules
6. CECE – Clinical Editing Criteria for UM at the Product Level
7. CLUM – Claim UM matching parameters (tiers)
8. DUMD – Duplicate Claim rules
9. DUUM – Duplicate UM Rules
10. EAAR – Clinical Editing Administrative Rules
11. IPMC – Procedure UM Definition – Defined at the Procedure code level, overrides
what is on the SEDF
12. MCRD – Auto Action criteria – generates letters, ID Cards
13. NPPR- Non-Par Provider relationship – required for OON Agreements in order for claims
to properly adjudicate
14. OLOL – Other party liability
15. PCAG – Processing Control Agent- last step in claims processing, allows for pends to be
configured based on varying criteria
16. PDBL- Billing component for premium reconciliation
17. SEDF – Default Service Definition - if no Agreement match occurs during claims
processing this is the default SEDF used
18. SEGR – UM service group – list of TOS groups for authorization purpose
19. SPCT – Supplemental Procedure Conversion Table
20. SRCT – Supplemental Revenue Conversion Table
21. UTSE – Medical Utilization Edits
22. WMUD – User Defined Warning Messages
Defined under the Description table in Application Support
Based on Applications
23. WMWM – Warning Messages
What are the 3 things the SEDF (Service Definition) controls?
1. Pricing;
2. Capitation
3. Pre-Authorization requirements
What are the 3 things the SEPY (Service Payment) controls?
1. Deductibles
2. Co-Payments
3. Limits
Class/Plan Review:
Open Via Group ID and Class ID
Indicative: Lists Description and Procedure, Revenue and Service Conversion Prefix
Plans: Lists all Plan IDs and Product IDs (Class Plan Information)
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Product Review:
Indicative – Application Type (Medical v. Dental), Product Type (Medicaid) Claims
Processing, Pre-Authorizations, Capitation, Premium Indicator (C – Convention Premium
Calculation), State Determination for Claim Interest (S – Subscriber Home Address)
Business Info – Alternate LOB used for PPO
Component- 23 components, series of rules for that particular Product
Variable Component – 3 sets of Benefit Rules that drive Service Payment, Deductibles,
Service Rules (Standard, Accident in Area, Emergency in Area) no difference between the 3
– ties to section on the Indicative section of the claim
Describe the Security Levels in Facets:
Security for Claims Batch processing is set to 7, therefore if there is a security level set higher than 7
the claim will not stop processing, it is information only.
Describe the Provider to Member Match Logic in Facets:
1. Does the Member have a PCP assigned? Is there a covering network set under the Group
ID and Class ID for the member?
Note* If No PCP assigned cannot calculate the covering set
2. If the Provider is the member’s PCP then is there a match to the “YES” row on the NWPR
row for the provider based on the member’s Network set under the Class/Plan Information
3. If the Provider is not the Member’s PCP then it searches for a “NO” row in the NWPR
table for the provider based on the member’s Network set under the Class/Plan Information
4. If there is not a match on the NWPR row then it looks at the NPPR and matches on the
Product prefix assigned to the member’s product on the Component table
5. If there is no match on the NPPR row then the system treats it as a true Non-Par and
proceeds to the default SEDF on the Component Table
How is a PCP identified in Facets?
The Provider has a YES row on their NWPR row in the Networks section
How does the claim adjudication routine start in Facets? - F3 the claim
What is the Medical Utilization Edits Application used for?
1. Hierarchy of Care (ASC, Observation, ER)
2. Allows for auth parameters to be set for certain services that normally would require an auth
but if billed in conjunction in an ER or other setting would not require an authorization
During claims adjudication how can you tell what prefixes were applied?
Go to View, Products and Prefixes. You must first F3 the claim
Accident/Emergency section of the claim during claims adjudication controls which row of the
variable component is used on the member’s product.
Where do the Limit Rules and Service Payment on the claim come from?
The Product Variable Component
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