Validate a Benefit Plan

Prove that the plan resolves for the intended date, presents understandable benefits, and drives a synthetic claim to the expected cost-sharing result.

Validation has two layers

The member view confirms what the plan says on a specific date. A real synthetic 837 confirms what the adjudication pipeline does with that exact plan. Use both before considering configuration complete.

1. Run the Configuration Checks

Open Configuration → Benefit Plans.
Open the plan you want to prove and select Validation.
Choose the intended service date, then select Refresh validation.

The portal checks effective dates, publication state, covered benefits, network tiers and identifiers, exclusions, and the date-sensitive member view. The snapshot also shows the deductible, out-of-pocket maximum, and accumulator model that a member experience would receive.

Benefit plan Validation tab showing successful effective-date, published-version, covered-benefit, network-tier, and member-view checks. — The selected published version resolves into ten member-facing benefit categories for the chosen service date.

Warnings deserve a decision

A warning does not always block testing. For example, a plan may intentionally have no explicit exclusions. Record that decision instead of treating every warning as an error.

2. Send a Plan-Specific Synthetic 837

In the Synthetic 837 proof section, confirm the test provider NPI, procedure code, and charge, then select Run synthetic 837. The demo workflow provisions isolated synthetic member, coverage, provider-network participation, and network fixtures when needed; uploads an actual X12 837P; and waits for the ordinary claim projection.

This is materially stronger than a calculator preview: the claim passes through the same intake, validation, plan resolution, provider gates, benefit calculation, disposition, and persistence stages used by other claims.

Metered and load-test safety

The write-producing test is available automatically in Development and Local Demo. In another approved demo environment, enable Features:BenefitPlanSyntheticValidationEnabled. It is off by default in production-style environments and is not invoked by Million Claim Challenge runs.

3. Read the Result

First confirm that Resolved plan matches the plan you opened. Then review the terminal claim status, network tier, billed and allowed amounts, plan payment, deductible, copay, coinsurance, and member responsibility. A denied or pended result can still prove that the pipeline is healthy when the reason reflects an intentional business or integrity rule.

Synthetic 837 validation result showing the exact resolved benefit plan, terminal claim status, network tier, and financial responsibility amounts. — The portal ties an actual 837 claim back to the selected plan version and presents the adjudication evidence in one place.

Evidence	What it proves
Exact plan ID and version	Coverage resolution did not silently select a fallback plan.
Network tier	Provider participation mapped to the intended plan network.
Allowed and paid amounts	Pricing and payer liability completed.
Deductible, copay, and coinsurance	The configured benefit rule and accumulators drove member cost sharing.
Outcome reason and claim ID	Operators can explain the disposition and continue into the full claim trace.

Completion check

The configuration checks are explainable, the member view matches the design, and the synthetic 837 resolves the selected plan version with a traceable adjudication result.

Refresh the Screenshots with Playwright

The checked-in browser workflow can reproduce the plan screenshots from synthetic local data:

Shellsrc/site

npm install
GUIDE_PLAN_ID=GUIDE-PPO-2026 npm run guides:capture:benefit-plans

The workflow replaces the images under src/site/graphics/user-guides/benefit-plans/, including the configuration checks and final synthetic-claim evidence.

Troubleshooting

Symptom	Likely cause
Member view does not resolve	Plan ID, tenant, publication state, or service date does not select an effective version.
Synthetic button is unavailable	The environment is neither Development nor Local Demo and the explicit feature flag is off.
Claim resolves a different plan	Inspect the synthetic coverage and exact plan ID before reviewing benefit rules.
Network tier is not assigned	Review provider participation, the plan tier’s network ID, and participation effective dates.
Claim is pended or denied	Read the displayed reason and full adjudication trace; provider-integrity and other fail-closed gates may be working as designed.
Unexpected cost sharing	Inspect the selected service category, network tier, rule applicability, and accumulator state.