Healthcare payer domain knowledge for IT teams

How the healthcare — payer business actually flows

Health plans, insurers and government programmes — how members are enrolled, care is authorised and claims are adjudicated and paid. Every session in this track hangs off this one flow, so you always know which part of the business you are looking at.

1. Design the plan
2. →
3. Build the network
4. →
5. Enrol members
6. →
7. Authorise care
8. →
9. Adjudicate claims
10. →
11. Pay & report

The nine layers of the Healthcare — Payer domain

Every BDC track answers the same nine questions in the same order, so knowledge from one domain transfers to the next. Here is what each layer looks like in Healthcare — Payer.

Sessions in the Healthcare — Payer track

Ten sessions, one per framework layer, closing with a proctored certification assessment. Session 01 is free for everyone, in English and Telugu, and Session 02 is free with a free account.

1. HPY-S01

   Healthcare — Payer at a Glance

   Released

   How a health plan really works — who it covers, who funds it and how a claim gets paid. The nine-stage payer journey, the systems and EDI transactions behind it, and what QA must test.

   • What a payer is — and the four main types
   • The nine-stage payer journey
   • Who funds the plan — follow the money
   • The systems and X12 transactions behind a payer
   • Claim adjudication, compliance and the QA view
   • Member
   • 834
   • 837
   • 835
   • Adjudication
2. HPY-S02

   How a Health Plan Makes Money

   Upcoming

   Premiums, capitation and risk — and the numbers a payer's finance and operations teams watch every month.

   • Fully insured, self-funded (ASO) and government funding
   • Medical loss ratio and the 80/85 rule
   • Cost PMPM and the medical cost trend
   • Auto-adjudication rate and cost per claim
   • Star ratings, HEDIS and risk adjustment
   • MLR
   • PMPM
   • ASO
   • Capitation
3. HPY-S03

   Enrol to Pay: The Payer Process

   Upcoming

   Design, network, enrol, serve, authorise, adjudicate, pay, manage care, renew — and what each step must capture.

   • Benefit design and the drug formulary
   • Provider credentialing and contracts
   • Enrollment, open enrollment and life events
   • Prior authorisation and utilisation management
   • Adjudication, payment, appeals and renewal
   • Enrollment
   • Prior auth
   • Adjudication
   • Appeal
4. HPY-S04

   The Payer Systems Landscape

   Upcoming

   Core admin, enrollment and billing, provider data, care management, pricing, EDI gateway and portals — what each one owns.

   • Core admin system — Facets, QNXT, HealthRules Payer
   • Enrollment and premium billing
   • Provider data management and the directory
   • Utilisation and care management
   • EDI gateway, portals, CRM and the data warehouse
   • Core admin
   • PDM
   • UM
   • EDI gateway
5. HPY-S05

   Member, Provider & Claim Data

   Upcoming

   The entities, code sets and identifiers that every payer screen, file and report depends on.

   • Subscriber, member, group and benefit plan
   • Provider, contract and fee schedule
   • Claim header, claim lines and accumulators
   • ICD-10-CM, CPT / HCPCS, revenue codes and DRG
   • Member id, NPI, TIN, ICN and the authorisation number
   • Member id
   • NPI
   • Accumulator
   • ICN
6. HPY-S06

   X12 834 to 835: Payer Integrations

   Upcoming

   How a payer talks to employers, providers, clearinghouses, banks and regulators — and where the files break.

   • 834 enrollment and 820 premium payment
   • 270/271 eligibility and 276/277 claim status
   • 278 prior authorisation
   • 837 claims, 999 and 277CA acknowledgements
   • 835 remittance, EFT and the CMS FHIR APIs
   • X12 5010
   • 834
   • 835
   • FHIR
7. HPY-S07

   Follow One Claim, End to End

   Upcoming

   A single claim traced from the member's enrollment file to the payment landing in the provider's bank.

   • Member enrolled on the 834
   • Eligibility checked with a 270/271
   • Authorisation approved on a 278
   • 837 received, edited, priced and adjudicated
   • 835 and EFT sent, EOB to the member
   • 834
   • 278
   • 837
   • 835
8. HPY-S08

   Testing Payer Systems

   Upcoming

   The six areas where payer defects live — and why every EDI change needs its own test file.

   • Enrollment adds, changes, terms and retro dates
   • Eligibility boundary dates and dependents
   • Auth-to-claim matching
   • Benefit, pricing, COB and accumulator rules
   • 835 balancing, PHI masking and audit trails
   • Enrollment
   • COB
   • CARC
   • PHI
9. HPY-S09

   Real-World: The Open-Enrollment File That Failed

   Upcoming

   An 834 full file fails to load just before 1 January — and thousands of new members have no coverage.

   • How the companion-guide change slipped through
   • Members inactive on the effective date
   • The war room and the corrected mapping
   • Reprocessing and reconciling the file
   • The pre-production test file that would have caught it
   • 834
   • Incident
   • Reconciliation
   • Prevention
10. HPY-S10

    Healthcare Payer Certification Assessment

    Upcoming

    The whole payer track in one place — a short recap video, then a proctored online assessment that applies all nine framework layers to a real-world scenario.

    • Nine-layer recap of the payer domain
    • The five things most people get wrong
    • 30 questions · 45 minutes · 60% to pass
    • Webcam-proctored, one question at a time
    • Certificate with a verifiable ID
    • Assessment
    • Certification
    • Proctored
    • Nine layers

Healthcare — Payer terms you will hear on every project

The vocabulary that separates someone who can follow a healthcare — payer requirements discussion from someone who cannot.

• 834
• 270/271
• 278
• 837
• 835
• CARC

Certified Healthcare — Payer Domain Practitioner — BDC-HPY

Finish the ten sessions, pass the online proctored assessment, and submit a scenario analysis to earn this domain's certificate. Each domain certifies separately.

Common questions