Health Care Domain Course Contents.


The health care industry is possibly the fastest growing domain in the United States. In the past 15 years major government mandates and regulations like HIPAA, NPI, ICD, HITECH and ACA have infused substantial investments across all major organization types. Competitive advantage of the payers in terms of medical loss ratio is a continuous challenge. Data science, machine learning and preventive care is performing a stellar role in realizing those goals. This course is tailor-made for the next generation business/ quality analyst who is ready to plunge into this gripping arena, supplement their skill-set with concrete knowledge through a riveting but compact series of classes, assignments and project work.

Duration: Hours: 25, 1 month course

Core Topics

  1. Introduction to US health care system
    • Domain pillars
    • Regulations, compliance and mandates
    • HIPAA Law
    • Terms and terminology
    • Administrative and Clinical Functional division
    • Managed Health concept
  1. Product Design
    • Basic concepts and flow diagram
    • Service types and benefit types
    • Schedule of benefits, fulfillment
    • Dive into analytics
    • Benefit package and products
    • Line of business
    • Group and individual market
    • QHP and MLR
    • Public and Private Exchanges
  1. Introduction to administrative transactions
    • A look into basic HIPAA X12 transactions
    • 270-271 , 837i/p/d , 276-277, 278-13, 278-11, 835, 834, 820, 275
    • CMS-1500 and UB04 forms
    • Crosswalks and gateway systems
  1. X12 concepts deep-dive
    • Building blocks of a X12 transaction
    • Business analysis life-cycle between trading partner interactions
    • Segments, elements and rule-sets
    • Data mapping using the implementation guide (TR3 reports)
    • Companion guides
    • VCML and transport mechanisms
  1. Clearing House
    • clearing houses as independent TPA
    • M-1 and M-M (B2B) models
    • Use Cases and companion guide integration
  1. Codes
    • Local and global code sets
    • Diagnosis, procedure, health care status, remark, NDC, taxonomy LOINC codes
    • ICD 9 – ICD 10 conversions
    • General equivalence mapping
  1. Claims Processing
    • E2E Payer system layouts
    • Claims processing and adjudication steps including claim check rules
    • Finance and revenue management
    • Warehousing and audit process
    • Fee schedule based vs. Capitation
    • Facets documentation
  1. Medicare and Medicaid
    • Overview of the programs
    • Qualification criteria
    • Medicare advantage and Medicare supplementary
    • Medicare cross-over claims
    • Coordination off benefits
    • State Medicaid programs , MITA architecture
  1. Pharmacy
    • Rx benefits
    • Pharmacy Benefit managers
    • Formulary and manufacturers
    • E-prescription and integration with EMR systems
    • NCPDP claims , encounter reporting
  1. Clinical Data Management
    • Electronic health records
    • Individual, payer based and provider based records
    • ADTs and ORU transactions
    • CCDA transactions
    • Microsoft HealthVault platform and integration
    • EMR systems and use cases
    • HITECH bill and certified EHR
    • National Health Information network
  1. Preventive Care
    • Utilization Management
    • Case and Disease management
    • Care Management and alerts
  1. A look at new technology usage in healthcare
    • Cloud service usage
    • Big Data
    • AI and Machine Learning
    • Blockchain

Other information:

Assignments rolling into Projects

  • Clearing House integration with Payer for 837p and 276 transactions includes X12, data mapping, companion and implementation guides.
  • PAPI to NPI conversion using LUHN algorithm
  • Member website use case modeling
  • Enterprise imaging systems conversion of paper claims to electronic forms
  • Microsoft health vault integration with third party wellness services
  • Open EMR reverse engineering
  • Includes XML, SQL, WSDL, Data Mapping, use case, UML, supp specs, JAR, wire-frames,

End of the course activities

  • Question bank from interviews walk through
  • Interview questions, demo of answers and open discussion
  • Mock interview sessions
  • Resume preparation and critic
  • One on one individual sessions with all class students


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