17 terms you will hear on a Healthcare — Payer project, each with what it means, where it shows up in the business, and what QA should test.
834 · 270/271 · 278 · 837 · 835 · Adjudication · CARC and RARC · Accumulator · COB · Prior authorisation · NPI · ICN · MLR · PMPM · ASO · Capitation · Core admin system
The file an employer or exchange sends a health plan to add, change or end members' coverage.
Where it shows up: Enrollment, often as a full file at open enrollment and change files after that.
What QA should test: Adds, terms and changes, dependants, effective dates, and the full-versus-change file logic.
A provider asks "is this member covered, and for what?" (270) and the payer answers (271).
Where it shows up: Before a visit or procedure.
What QA should test: Responses for active, termed and future members, and benefit details that match the plan set-up.
The X12 transaction for prior authorisation and referrals: requesting approval before a service.
Where it shows up: Utilisation management, before high-cost care.
What QA should test: Approve, pend and deny paths, turnaround clocks, and the authorisation reaching claims adjudication.
The claim a provider submits: 837P for professional, 837I for institutional and 837D for dental.
Where it shows up: Claims intake through the EDI gateway.
What QA should test: File validation, front-end rejections, duplicates, and every field mapped into the claims system.
The payer's explanation of what it paid on each claim line and why, sent with or alongside the payment.
Where it shows up: After adjudication, to the provider.
What QA should test: Paid amounts, adjustment codes and balancing: every line must add up.
Deciding what to pay on a claim: checking eligibility, benefits, authorisation, pricing, edits and member cost share.
Where it shows up: The core of the claims system.
What QA should test: Auto-adjudication rules, pends to manual review, pricing and cost-share calculations.
Standard codes on the 835 that explain why a claim line was paid differently from what was billed.
Where it shows up: Remittance to providers, and denial management on the provider side.
What QA should test: The right code for each denial or adjustment, and code-list updates.
A running total of what a member has paid toward their deductible and out-of-pocket maximum in the plan year.
Where it shows up: Every adjudicated claim, and pharmacy claims too.
What QA should test: Accumulation across medical and pharmacy, resets at plan year, and family versus individual limits.
Rules for which plan pays first when a member has more than one insurance, and how the second plan pays.
Where it shows up: Eligibility and claims.
What QA should test: Primary and secondary order, the birthday rule for dependants, and secondary claims using the primary's payment.
Approval the plan requires before certain services or drugs are covered.
Where it shows up: Utilisation management.
What QA should test: Auth matching on the claim (dates, codes, provider) and denials when it is missing.
The 10-digit ID the US gives every healthcare provider, individual or organisation.
Where it shows up: Provider data, claims and payments.
What QA should test: NPI format and check digit, and claims matching the right provider and contract.
The unique number a payer assigns to each claim when it is received, used to track it through adjustments.
Where it shows up: Claims intake onwards.
What QA should test: Unique numbering, and adjustments and reversals linked to the original ICN.
The share of premium a plan spends on medical care and quality improvement. In the US the ACA sets minimums of 80% or 85% depending on the market.
Where it shows up: Finance and regulatory reporting.
What QA should test: Report inputs and reconciliation to claims paid.
A cost or revenue figure divided by members and months, so plans of different sizes can be compared.
Where it shows up: Finance, actuarial and provider contracts.
What QA should test: Member-month counts from enrollment, and correct date ranges.
An arrangement where an employer funds its own claims and the payer only administers them.
Where it shows up: Group set-up, claims funding and reporting.
What QA should test: Funding and billing per group, and reports that separate ASO from fully insured business.
A fixed payment per member per month to a provider, whatever services the member uses.
Where it shows up: Provider contracts and payments.
What QA should test: Capitation runs against eligibility, retro adds and terms, and encounter claims that pay zero.
The payer's main platform for members, providers, benefits and claims. Facets and QNXT are common examples.
Where it shows up: Everywhere in payer operations.
What QA should test: Configuration changes (benefits, pricing, edits) tested with regression claim sets before release.
The Healthcare — Payer track walks through the whole business end to end, and Session 01 is free in English and Telugu.
