User Acceptance Testing----HEALTH CARE DOMAIN

How to Test a Healthcare Application?

An Insurer requires different applications to manage the following −

 Provider data
 Member data
 Premium billing/payment
 Broker data
 Claims entry/validation

In most cases, a healthcare application will include the following systems −

 Member system − To keep track of policyholder information, as well as various plans

and their benefits lists, and to create premium bills for policyholders based on their plans.
 Provider system − to keep track of provider information
 Broker system − To keep track of broker information and calculate commissions
 Claims system − For submitting and validating claims
 Finance system − To make the required payments to the supplier, member, or broker
 Member Portal − View policyholder information, pay premiums, and submit a request
for policyholder information changes.
 Provider portal − To display provider information and submit a change request for
provider information.
 Broker portal − displays broker information and allows brokers to seek changes to their
information.

Testing of Member System

Sample Test Scenarios for Member (Patient) System −

Test Scenario Test Cases

 Enroll, re-enroll, and dismiss a member.

 Remove the dependency and replace it with a new
Member
one.
system
 Make a premium bill.
 Process payments for premiums.

Positive Flow  Enroll different sorts of members based on the

 User Acceptance Testing----HEALTH CARE DOMAIN

Test Scenario Test Cases

current, past, and future effective dates.

 Inquire about and replace members.
 Prepare a premium bill for an active member for
the month ahead.
 Terminate an active member with a termination
Testing
date greater than the effective date in the past,
present, and future.
 Re-enroll a terminated member using his or her
current, previous, and future effective dates.

 Enroll a member with inadequate data

Negative flow
 Prepare a premium bill for the following month for
Testing
a terminated member.

Testing of Claims System

Sample Test Scenarios for Claims System −

Test Scenarios Test Cases

 Health-care claims should edit, enter, and

process claims for both members and
Claim System dependents.
 When inaccurate data is entered for invalid
claims, it should throw errors.

 It should include the scenario of editing,

Positive Flow
entering, and processing claims for both
System Testing
members and dependents.

Negative Flow  It should validate and submit a claim with a

System Testing procedure code and diagnosis code that are
both invalid.
 Use the inactive provider ID to validate and
enter a claim.
 Validate and enter a claim for a member who
 User Acceptance Testing----HEALTH CARE DOMAIN

Test Scenarios Test Cases

has been terminated.

 A scenario should be included to validate the

System
feed to downstream systems such as provider
Integration
and finance portals.

Testing of Claims System

Sample Test Scenarios for Claims System −

Test Scenarios Test Cases

 Health-care claims should edit, enter, and

process claims for both members and
Claim System dependents.
 When inaccurate data is entered for invalid
claims, it should throw errors.

 It should include the scenario of editing,

Positive Flow
entering, and processing claims for both
System Testing
members and dependents.

 It should validate and submit a claim with a

procedure code and diagnosis code that are
both invalid.
Negative Flow
 Use the inactive provider ID to validate and
System Testing
enter a claim.
 Validate and enter a claim for a member who
has been terminated.

 A scenario for validating the feed to

System
downstream systems such as the provider and
Integration
finance portal should be included.

Testing for regulatory compliance

 User Acceptance Testing----HEALTH CARE DOMAIN

Health regulatory bodies place a high focus on safeguarding patient sensitive

data and health information. The testing should be carried out in accordance
with the requirements of such regulatory authorities.

Sample Test Scenarios and Test cases for Regulatory Compliance −

Test Scenarios Test Cases

 Using a verification mechanism to verify

User's
that only the correct users gain a login
Authentication
and to prevent others from doing so.

 Access to information is granted based

Information
on the user's job and the patient's
Disclosure
limitations.

 Points ensure that data is encrypted at all

Data Transfer
times.

 With a correct set of audit trail

Audit Trail information, all transactions and
attempts to access data are logged.

 Perform sanity checks and confirm that

Sanity Testing
data encryption is in place in certain
related to
places such as EPHI (Electronic
regulatory body
Protected Health Information)