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. 
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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 :-
  • PHI
  • Health care plans
  • Subscriber
  • Member
  • Coverage Type
  • Enrollment, Effective and Termination Dates
  • Capitation
  • Provider
  • Claims
  • Coinsurance
  • Copayment
  • Deductible
  • FSA (Flexible spending accounts or arrangements)
  • MSA (Medical saving account) / HSA (Health spending account)
  • COB
  • TPL
  • ICD Codes - ICD9 vs. ICD10
  • HL7 (Inbound/Outbound)
  • Section 111 Reporting

Government Health Care Plans

  • Medicaid
  • Eligibility
  • Coverage
  • Medicare
  • Eligibility
  • Coverage

Commercial Healthcare Plans

  • Preferred provider organisation (PPO) 
  • Exclusive provider organisation (EPO)
  • Health maintenance organisation (HMO)
  • Supplemental Insurance
  • Medigap


  • 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
  • Concerns
  • Things to accounts for
  • Analysis Guidelines
  • Testing Considerations


  • Coordination of Benefits (COB)
    • What is COB?
    • Why COB?
    • COB Rules
  • Third Party Liability (TPL)
    • What is TPL?
    • Why TPL?
    • TPL Rules

I hope you will enjoy this article about US Healthcare Basics. I would like to have feedback from my blog readers. Your valuable feedback, question, or comments about this article are always welcome. Also If you like this article, don't forget to share this article with your friends and colleagues.
US Healthcare Domain Knowledge Tutorial Reviewed by Ravi Kumar on 10:22:00 PM Rating: 5

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