US Healthcare Domain Training

• What is Health care
• Health Insurance
• Major entities oh Healthcare
• Basic Hospital Flow
• Types of of Insurance

• Member eligibility
• Member Enrollment
• Member Services

Creating Cross-Tabulated Reports using:

• Who is a provider?
• Types of Provider
• Types of provider facilities
• Provider Contracting
• Key Information about Providers
• In - network and out - Network
• Why OON provider

Creating Cross-Tabulated Reports using:

• What is a Health plan
• Types of Health plan
• Plan Key Information
• Benefit Determination
• OOP
• Indemnity Plans
• Commercial plans(HMO,PPO,POS)
• Consumer Driver Health plan
• Medicare,Medicaid,Medigap,SHIP

Creating Cross-Tabulated Reports using:

• Overview of Claims
• Claim life cycle Introduction
• Pre Adjudication
• Authorization and Referral
• Coordination of Benefits
• Claim Edits
• Claim Adjudication
• Post Adjudications
• EOB
• Electronic Remitance Advice - ERA

Creating Cross-Tabulated Reports using:

• What is PHI
• HIPPA privacy rules
• HIPPA Benifits

Creating Cross-Tabulated Reports using:

• EDI uses
• 837 Claims Form
• EDI Facts
• EDI Transactions
• Basic X12 Formats
• EDI File Layouts

Creating Cross-Tabulated Reports using:

• Fraud and Abuse
• Types of Fraud
• Stark Law

Aster Health – Health plan selection management

Aster Health wants to enable a mobile application where individuals will be able to use it for enrolling in new plans, check their coverage and eligibility, Find Care and Costs and View Claims submitted. The healthcare payer wants to replace the existing manual member enrolment and inquiries, with an easy access online portal/mobile application. The company has signed a multi-year deal with TransTech Inc to develop and manage the new system.

Project Objectives: Create the process flow for the member to search and select health plans in order to consider for enrolling, if satisfied with health plans offered.

Daisy Hospitals – Member Eligibility Verification

Daisy Hospitals wants to enable a web application where the Provider or Provider’s office personals will be able to verify the eligibility of patients who book an appointment for an encounter with a Physician. The hospital expects to reduce the number of calls made to the Payer for verifying Patient’s eligibility. The company has signed a multi-year deal with eHealth Inc to develop and manage the eligibility verification system.

Project Objectives: Create the process flow for the Provider or Provider office personnel to submit the eligibility verification request.