Top 50 Facets Interview Questions You Must Know – Expert-Curated List
Basic Facets Interview Questions (For Freshers)
1. What is Facets?
Answer: Facets is a core administrative processing system developed by Trizetto for healthcare payers. It helps manage claims processing, enrollment, billing, provider networks, and more.
2. What are the main modules in Facets?
Answer: Key modules include Membership, Claims, Billing, Provider, Benefits, Customer Service, and Workflow.
3. What is a Plan in Facets?
Answer: A plan in Facets defines benefit structures, copayments, deductibles, and eligibility rules associated with members.
4. Define a Member in Facets.
Answer: A member refers to an individual enrolled in a health insurance plan, represented by a unique subscriber/member ID.
5. What is a Subscriber in Facets?
Answer: A subscriber is the primary person covered under the policy. Dependents are added under the subscriber.
6. What is the difference between Subscriber and Member in Facets?
Answer: All subscribers are members, but not all members are subscribers. Dependents are members, not subscribers.
7. What is a Claim in Facets?
Answer: A claim is a request for payment from a provider or member to the insurance company for covered services rendered.
8. How is billing handled in Facets?
Answer: Facets uses the Billing module to manage premium invoices, payments, and account balances.
9. What is the role of the Provider module?
Answer: It manages provider data, including contracts, networks, specialties, and payment arrangements.
10. What is the Benefit Configuration in Facets?
Answer: It involves defining coverage details such as copays, limits, exclusions, and service groupings.
Intermediate Facets Interview Questions (2–5 Years Experience)
11. What is a Workflow in Facets?
Answer: Workflow in Facets automates business processes by routing tasks and managing work queues.
12. What is the purpose of a Queue in Workflow?
Answer: A queue stores tasks assigned to specific users or groups for processing.
13. Does Facets handle Eligibility Verification?
Answer: Eligibility is determined by plan rules, member effective dates, and coverage details.
14. What is Coordination of Benefits (COB) in Facets?
Answer: COB ensures claims are paid appropriately when a member has coverage under more than one plan.
15. How is a Claim Adjusted in Facets?
Answer: Claims can be adjusted to correct errors or reprocess based on new information using the claim adjustment feature.
16. Explain Pricing and Adjudication in Facets.
Answer: Pricing determines payment amounts, and adjudication applies rules to validate and settle claims.
17. What is the difference between Institutional and Professional Claims in Facets?
Answer: Institutional claims are for facility services; professional claims are for individual provider services.
18. How do you configure a new Benefit Plan in Facets?
Answer: Through the Benefits module, using service categories, accumulators, and limits.
19. What is EDI in Facets?
Answer: Electronic Data Interchange (EDI) allows data exchange (e.g., claims, enrollment) between systems.
20. What is the importance of HIPAA in Facets?
Answer: HIPAA mandates standards for protecting patient data and electronic transactions processed in Facets.
Advanced Facets Interview Questions (5+ Years Experience)
21. What are Accumulators in Facets?
Answer: Accumulators track usage against benefit limits (e.g., deductible met, visits used).
22. Explain Facets Data Model.
Answer: It includes tables grouped by modules (e.g., Claims, Provider) with primary keys like SUBS_ID, CLM_ID, etc.
23. How are Claims routed in Facets?
Answer: Claims are routed via workflows, edit checks, and adjudication rules for processing and review.
24. What is Facets Batch Processing?
Answer: Batch jobs run system processes (e.g., eligibility updates, claim pricing) outside regular hours.
25. Explain 837 and 835 in EDI.
Answer: 837 is the standard for submitting claims, while 835 is for remittance advice/payment.
26. How do you troubleshoot claim denial issues in Facets?
Answer: Review denial codes, audit rules, provider contracts, and benefit eligibility.
27. What is a Facets Extension?
Answer: It allows customization or enhancement of standard Facets functionality without altering base code.
28. What is the use of TCN (Transaction Control Number)?
Answer: It’s a unique identifier for tracking EDI transactions and claims.
29. What is the difference between Real-Time and Batch Claims Processing?
Answer: Real-time processes claims instantly; batch processes a group of claims on a schedule.
30. What are the common tables used in Claims processing?
Answer: CLM, CLM_PROC, CLM_LN, PAYMT, DENIAL, etc.
31. How would you add a new provider in Facets?
Answer:
To add a new provider in Facets:
Go to the Provider module.
Click on “Add New Provider”.
Enter required fields like Provider ID, NPI, Name, TIN, Specialty, and Taxonomy code.
Add addresses, contact information, and assign contract and network affiliations.
Configure licensing and credentialing.
Review for accuracy, then save and activate the record.
Optional: Validate by running a test claim or searching in provider lookup.
32. A member’s coverage terminated incorrectly. How do you resolve it in Facets?
Answer:
Access the Membership module.
Search for the member/subscriber ID.
Review the coverage history and identify the incorrect termination.
Validate supporting documents (e.g., eligibility feed, employer records).
Reverse the termination or adjust the termination date.
Update the coverage record with correct effective and end dates.
Save changes and, if needed, resubmit impacted claims.
33. Describe the process of loading new EDI claim files into Facets.
Answer:
Place the 837 EDI file into the designated inbound directory.
Trigger the EDI loader job, either manually or as scheduled in batch.
The system parses and converts the EDI file into claim records.
Check load logs for errors (e.g., format issues, missing data).
Successfully loaded claims appear in pending or ready-to-process status.
Failed records can be corrected and resubmitted.
34. How do you investigate an overpayment issue in Facets?
Answer:
Go to the Claims module and retrieve the claim by ID or member.
Verify the billed vs. allowed amount, contract pricing, and benefit configuration.
Check for duplicate payments, incorrect adjudication rules, or manual overrides.
Review associated provider contract and COB details.
If confirmed, initiate a claim adjustment or recoupment via recovery process.
Document and report the issue for audit trail.
35. What steps do you take to configure COB logic?
Answer:
Navigate to COB configuration settings in Facets.
Set rules for primary/secondary payer determination.
Define payer hierarchy and tie it to member/subscriber records.
Configure claim edit rules for COB processing (e.g., duplicate check, benefit coordination).
Update EDI mappings for 837 and 835 COB segments.
Test sample claims for proper adjudication and payment.
Ensure compliance with HIPAA and payer policies.
36. A provider is not reimbursed as per contract. What will you check in Facets?
Answer:
Verify the contract association in the Provider module.
Check the contract terms: fee schedule, reimbursement methodology, effective dates.
Review the claim details (e.g., CPT codes, place of service).
Compare claim pricing with contract rates.
Ensure correct network and product mapping exists.
Check if any manual override or incorrect pricing logic applied.
Correct and reprocess the claim if needed.
37. How do you identify duplicate claims in Facets?
Answer:
Use claim search with filters on member ID, DOS (Date of Service), provider, and procedure codes.
Check for system-generated duplicate claim edits or denials.
Analyze claim history for the same service rendered within the same timeframe.
Validate if claims were resubmitted or submitted in error.
Configure claim edit rules to auto-flag duplicates based on matching fields.
38. How do you generate custom reports from Facets?
Answer:
Use Facets SQL queries or built-in reporting tools (e.g., Crystal Reports, Cognos).
Access data via data warehouse or direct DB queries on key tables like
CLM,SUBSCRIPTION,PROVIDER.Define report requirements: filters, date range, grouping.
Run queries using tools like SQL Server, Toad, or Oracle SQL Developer.
Format data into Excel, PDF, or scheduled email reports.
Ensure PHI compliance in report content.
39. What if accumulators are not updating correctly?
Answer:
Review accumulator configurations in the Benefits module.
Validate accumulator rules, service types, and limits.
Check claim lines to see if eligible services were mapped to accumulators.
Inspect any manual adjustments or claim errors that might bypass update.
Ensure accumulators are not tied to inactive or incorrect plans.
Reprocess claims or run a batch accumulator job if needed.
40. Explain how you would audit a claim for accuracy in Facets.
Answer:
Retrieve the claim using claim ID or member ID.
Review all fields: diagnosis codes, procedures, provider, service dates.
Cross-check with benefit configuration, provider contract, and eligibility.
Validate the claim went through correct edits, pricing, and adjudication rules.
Confirm payments, denials, and adjustments match system logic.
Use audit logs and workflow history to track changes or overrides.
Document findings and take corrective actions if discrepancies are found.
Technical/SQL-Based Facets Interview Questions (Q41–Q50)
41. How do you extract member data using SQL from Facets?
Answer:
You can use a SQL query on the SUBSCRIPTION or MEMBER table.
Example:
This retrieves all subscription (member) details for the specified member ID.
42. How would you join claim and provider data?
Answer:
To join claims and provider information, use CLM (claims) and PROVIDER tables via the PROV_ID field.
Example:
43. What indexing strategy would you use on large Facets tables?
Answer:
Use composite indexes on frequently joined or filtered columns (e.g.,
CLM_ID,SUBS_ID,PROV_ID,CLM_DATE).Regularly maintain indexes via rebuilds or reorgs.
Avoid over-indexing; balance performance and storage.
Analyze execution plans to optimize slow queries.
44. How do you handle performance tuning in Facets reports?
Answer:
Use indexed columns in WHERE clauses.
Avoid SELECT *; specify only necessary fields.
Use CTEs or temporary tables for complex joins.
Minimize use of subqueries and cursors.
Schedule large reports during off-peak hours.
Utilize query execution plans to troubleshoot bottlenecks.
45. What are some commonly used Facets APIs or web services?
Answer:
Facets Web Services for claims, eligibility, membership updates.
Common APIs include:
CheckEligibilityServiceSubmitClaimServiceGetMemberDetailsService
These support real-time integration with third-party apps or provider portals.
46. What is the difference between a Facets table and a view?
Answer:
A table stores actual data in the database.
A view is a virtual table derived from one or more tables via a SELECT query.
Views in Facets are often used to simplify access to complex joins or filtered data.
47. How do you implement version control for Facets configuration?
Answer:
Use a configuration management system or source control (e.g., Git, TFS) for scripts, XML config files, and workflow definitions.
Maintain a configuration change log with version numbers and rollback history.
Use Facets’ promotion processes for migrating changes across environments.
48. Describe your experience with Facets data migration.
Answer:
Involves extracting data from legacy systems, transforming it to match Facets schema, and loading into target tables.
Use ETL tools (e.g., Informatica, SSIS) or SQL scripts.
Validate using checksum counts, reconciliation reports, and business rule testing.
Perform dry runs and parallel processing for comparison.
49. What BI tools have you used to report on Facets data?
Answer:
Tools like Cognos, Power BI, Tableau, and Crystal Reports.
Create dashboards on claims volume, processing status, denial trends, and provider performance.
Data is sourced from Facets data warehouse or reporting views.
50. How do you perform unit testing after a Facets configuration update?
Answer:
Identify impacted modules (e.g., Claims, Membership).
Create test cases using realistic member, provider, and claim data.
Execute each use case and compare results against expected outcomes.
Validate configurations, rules, workflows, and accumulators.
Document results and perform regression testing if needed.
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