Health Insurance Specialist Course

Lesson 1 • Key Stakeholders in the System

Maps relationships amongst insurers, providers, employers, regulators, and members. Understanding stakeholder roles clarifies how decisions and payments flow.

Lesson 2 • History and Purpose of Health Insurance

Traces the evolution of health cover from mutual aid to modern managed care. Establishes why insurance exists and how it distributes financial risk.

Lesson 3 • Core Insurance Terminology

Defines essential vocabulary used throughout the industry. Accurate use of terms is required for all subsequent policy analysis and claims work.

Lesson 1 • Fraud, Waste, and Abuse Prevention

Identifies common fraud schemes and the legal consequences of non-compliance. Students apply detection techniques and understand reporting obligations.

Lesson 2 • Federal Regulatory Landscape

Covers federal laws governing cover mandates, portability, and consumer protections. Provides the baseline rules that all plans must meet regardless of state.

Lesson 3 • Compliance Programme Management

Outlines how organisations build and maintain effective compliance programmes. Connects regulatory knowledge to operational policies and staff training.

Lesson 4 • State Regulatory Authority

Explains how state insurance departments licence carriers and enforce solvency standards. Students distinguish federal floors from state-specific requirements.

Lesson 1 • Pharmacy Benefit Management

Covers formulary design, tier structures, and prior authorisation for drugs. Students can interpret pharmacy benefits and explain cost-sharing to members.

Lesson 2 • Plan Document Interpretation

Teaches students to read and apply summary plan descriptions and certificates of cover. Accurate interpretation prevents member disputes and claims errors.

Lesson 3 • Government-Sponsored Programme Benefits

Compares benefits under public programmes for elderly, low-income, and disabled populations. Students identify how these programmes interact with commercial cover.

Lesson 4 • Medical Benefit Structures

Details how inpatient, outpatient, and preventive benefits are structured within a plan. Establishes the benefit framework used in all subsequent claims and enrolment work.

Lesson 1 • Enrolment Periods and Rules

Defines open enrolment, special enrolment, and initial enrolment windows. Correct period identification prevents cover gaps and compliance violations.

Lesson 2 • Eligibility Verification Processes

Explains how eligibility is confirmed for members, dependents, and COBRA participants. Accurate verification reduces claim denials and audit risk.

Lesson 3 • Life Event and Status Change Processing

Covers how marriage, birth, divorce, and job loss trigger cover changes. Students apply event-driven rules to update member records accurately.

Lesson 1 • Diagnosis Coding Systems

Covers the structure and use of the international diagnosis classification system. Accurate diagnosis coding is the foundation of claims adjudication and data reporting.

Lesson 2 • Facility and Institutional Coding

Covers inpatient prospective payment groupings and outpatient facility coding. Students distinguish professional from facility billing to prevent duplicate payment.

Lesson 3 • Coding Compliance and Auditing

Applies compliance principles to coding accuracy and documentation integrity. Students identify upcoding, downcoding, and unbundling as audit targets.

Lesson 4 • Procedure Coding for Professional Services

Explains the current procedural terminology system for physician and outpatient services. Students select correct codes for evaluation, management, and surgical services.

Lesson 1 • Provider Credentialing and Enrolment

Details the verification process for provider qualifications, licensure, and sanctions. Credentialing protects members and is required before claims can be paid.

Lesson 2 • Network Performance Monitoring

Explains how quality metrics, utilisation data, and member feedback are used to evaluate providers. Performance data informs contract renewals and network changes.

Lesson 3 • Network Development Strategy

Explains how insurers design networks to balance access, quality, and cost. Students apply adequacy standards to assess whether a network meets regulatory requirements.

Lesson 4 • Provider Contracting Fundamentals

Covers the key terms, payment models, and negotiation principles in provider agreements. Contract terms directly affect claims payment accuracy and provider relations.

Lesson 1 • Benefit Application and Pricing

Explains how plan benefits, fee schedules, and network contracts are applied to determine allowed amounts. Accurate pricing requires integrating eligibility, coding, and contract data.

Lesson 2 • Claims Intake and Validation

Covers electronic and paper claim receipt, format validation, and initial edits. Clean claim submission reduces processing time and rework costs.

Lesson 3 • Denial Management and Appeals

Teaches the process for issuing, tracking, and resolving claim denials and member appeals. Effective denial management reduces rework costs and improves member satisfaction.

Lesson 4 • Coordination of Benefits

Explains rules for determining primary and secondary payer responsibility when members have multiple plans. Correct COB prevents overpayment and member balance billing.

Lesson 1 • Utilisation Management Programme Design

Explains the structure and regulatory requirements of a utilisation management programme. Students identify the types of review and the criteria used to make cover decisions.

Lesson 2 • Transitions of Care Management

Covers post-discharge follow-up, medication reconciliation, and readmission prevention. Smooth care transitions reduce costly readmissions and improve member safety.

Lesson 3 • Disease Management Programmes

Explains population-based programmes targeting chronic conditions such as diabetes and heart disease. Students evaluate programme design and measure impact on cost and quality.

Lesson 4 • Case Management Principles

Covers identification, assessment, and care planning for high-complexity members. Effective case management reduces avoidable hospitalisations and improves outcomes.