US Healthcare Domain Knowledge Tutorial
I personally believe that healthcare domain is the most complicated thing to understand. During healthcare software development project requires domain knowledge for developers. In terms of testing healthcare software is also a difficult task as it requires a vast knowledge of the healthcare domain.
- Must read What is meant by Domain Knowledge?.
|Healthcare domain knowledge for Business Analyst|
US Healthcare Terminology
US healthcare terminology can be complex, to say the least. There are following most common healthcare terminologies :-
- Health care plans
- Coverage Type
- Enrollment, Effective and Termination Dates
- FSA (Flexible spending accounts or arrangements)
- MSA (Medical saving account) / HSA (Health spending account)
- ICD Codes - ICD9 vs. ICD10
- HL7 (Inbound/Outbound)
- Section 111 Reporting
Government Health Care Plans
Commercial Healthcare Plans
- Preferred provider organisation (PPO)
- Exclusive provider organisation (EPO)
- Health maintenance organisation (HMO)
- Supplemental Insurance
- What is HIPAA (Health Insurance Portability and Accountability Act)?
- HIPAA Basics
- HIPAA Transactions
- 837 : Claim submission (Professional, Institutional and Dental)
- 834 : Enrollment (Benefit Enrollment and Maintenance)
- 820 : Premium Payments (Payroll Deducted and other group payment)
- 270/271 : Eligibility and benefits (Health care eligibility inquiry and response)
- 278 : Authorization (Health care service request for review and response)
- 4010 to 5010 conversion
Health care systems
- Member management
- Provider management
- Reimbursement Management (Claim Processing)
- Benefits Administration
- Prior Authorization
- Rate Setting
ICD 9 and ICD 10 Conversion
- What are ICD codes?
- Benefits of conversion
- Things to accounts for
- Analysis Guidelines
- Testing Considerations
COB and TPL
- Coordination of Benefits (COB)
- What is COB?
- Why COB?
- COB Rules
- Third Party Liability (TPL)
- What is TPL?
- Why TPL?
- TPL Rules
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