us healthcare system domain knowledge

Keywords | Healthcare Domain Knowledge for Business Analyst, healthcare domain knowledge for developers, us healthcare system overview

US Healthcare System Overview

The US healthcare system is the best healthcare system in the world. Find the below list of main entities of us healthcare model:-

  • Healthcare Provider/Doctor/Hospital/Facility
  • Health Insurance Provider/Payer
  • Member/Subscriber
  • Group and
  • Federal and State Governments

Understanding US Healthcare System

  • Health Insurance: It will be a contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium. 
  • Insurer/Payer: The insurance company whose plan pays to help cover the cost of your care. 
  • Primary Insurer: The insurance plan processes the claim first when a member has more than one group insurance plan covering the services. 
  • US Healthcare Providers: It can be any person (doctor or nurse)/institution (hospital, clinic or laboratory) that provides medical care.
  • Member/Subscriber: A person who is enrolled in a health plan (also called an enrollee or subscriber)
  • Group: It can be an Employer, Group Insurance
  • Plan: An individual or group plan that provides, or pays the cost of medical care.

Structure of US Healthcare System – How does US healthcare system work? 

This article provides a structure of US healthcare system, how does it work with the help of pictorial representation. Let’s find out:-

how does the us healthcare system work healthcare domain Healthcare Domain Knowledge for Business Analyst us healthcare overview 1

*EOB: Explanation of Benefits, which is a statement of the insurer that itemizes how benefits were approved or denied a claim.

US Healthcare System Terminology

US healthcare terminology can be complex, to say the least. Find the list below:-

  • PHI
  • Healthcare plan
  • Subscriber
  • Member
  • Coverage Type
  • Enrollment, Effective and Termination Dates
  • Capitation
  • Provider
  • Claims
  • Coinsurance
  • Co-payment
  • 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 (Benefits Enrollment and Maintenance)
  • 820: Premium Payments (Payroll Deducted and other group payment)
  • 270/271: Eligibility and benefits (Healthcare eligibility inquiry and response)
  • 278: Authorization (Healthcare service request for review and response)
  • 4010 to 5010 conversion

 Healthcare Management 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

 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

What do you think?

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