Testing Healthcare Applications – Tips and Important Test Scenarios (Part 2)

In the last article, we did some heavy lifting in terms of understand the healthcare domain. We are ready to put our “Tester’s hat” back on and now try to understand how to test the health care applications.

=> If you haven’t read part 1 please read it here: How to Test Health care application – introduction

We are now going to pick each application/system and come up with conditions that we are going to validate in each one of them.

This article is useful for the testers who are already in the healthcare domain or those who want to enter in this hottest career field.

Let’s get started!

Health insurance software testing

Healthcare Application Testing – The Sample Test Scenarios for:

Health Insurance System - Testing Components

Testing of Provider system:

1. Provider system should be let us enter, edit and save provider data.

2. Positive flow system testing- include scenarios to enter different types provider, change, save and inquire them.

3. Negative flow system testing- include scenarios to

  • Save a provider with incomplete data
  • Save a provider with contract effective date less than the provider license date
  • Enter data of provider which is already available in the system and save

4. System integration testing should include scenarios to

  • Validate the feed to downstream systems such as feed to member system, provider portal, claim system and finance system
  • Validate if the changes from provider portal are incorporated in the respective provider record

Testing of Broker system:

1. Broker system should be capable of the following,

  • Enter, edit and save broker data
  • Calculate broker commission based on the premium payment details from member system

2. Positive flow system testing should include scenarios to

  • Enter, edit and save broker record for different types of broker
  • Calculate the commission for the active broker by creating feed file with the respective record for members with different plan

3. Negative flow system testing should include scenarios to

  • Enter a broker record with insufficient data and save for different types of broker
  • Calculate the commission for the terminated broker by creating feed file with the respective record for members with different plan
  • Calculate the commission for the invalid broker by creating feed file with the respective record for members with different plan

4. System testing should include scenarios to

  • Validate the feeds to downstream system such as broker portal, finance system and member system
  • Validate if the changes from broker portal are incorporated in the respective broker record

Testing of Member system:

Member system should be capable of the following,

  1. Enroll, terminate, reinstate and re-enroll a member
  2. Add and remove a dependent
  3. Generate premium bill
  4. Process premium payments

Enrollment:

In individual policy, a policy holder is added under a plan with an effective date from which he/she will be paying premium for the benefits provided by the insurer and from which he/she is eligible for submitting claims and receiving coverage.

In Group policy, a member is added to the group (which is already added under a plan) with an effective date from which he/she is eligible for submitting claims and receiving coverage.

Termination:

In individual policy, the policy is terminated with a termination date from which a policy holder will not be covered by the insurance plan

In group policy, either the member alone can be terminated with a termination date or the whole group can be terminated.

Reinstatement:

If a terminated member asks for the policy to be active again and the current date is within the grace period from the termination date then the member can be reinstated without gap in coverage. The policy effective date will be the same old effective date and not the current date.

Re-enrollment:

If a terminated member asks for the policy to be active again and the current date is beyond the grace period from the termination date then the member can be re-enrolled with gap in coverage. The policy effective date will be the current/future date and not be the same old effective date.

For example, A member is enrolled in a policy with effective date as 1/1/2013 and terminated on 12/31/2013.let us take 30 days as the grace period fixed by the insurance company.

Case 1: If the member comes back at 1/15/2014 and wants the policy to be effective against then it is reinstatement if the member pays the premium for the period 12/31/2013 to 1/15/2014 then the policy effective date will be the same old 1/1/2013.

Case 2: If the member comes back at 2/1/2014 and wants the policy to be effective again then it is re-enrollment and the policy effective date will be 2/1/2014. Here there is a gap in coverage (1/1/2014 to 1/31/2014).

Positive flow system testing should include scenarios to

  • Enroll different types members with past, current and future effective dates
  • Change and inquire members
  • Generate premium bill for an active member for next month
  • Terminate an active member with past, current and future termination dates greater than effective date
  • Re-enroll a terminated member with past, current and future effective dates
  • Reinstate a terminated member

Negative flow system testing should include scenarios to

  • Enroll a member with insufficient data
  • Generate premium bill for next month for a terminated member

System integration testing should include scenarios to


  • Validate the feed to downstream systems such as member portal, provider portal, broker system, claim system and finance system
  • Validate if the changes from member portal are incorporated in the respective member record
  • Process the payment of generated premium bill with feed from member portal that has details of payment made

Testing of Claims system:

Claims in healthcare have diagnosis code and procedure code for the claim to be in detail.

  1. Diagnosis code – Refers to the disease the patient have
  2. Procedure code – Refers to the treatment provided to the patient

Claims system should be capable of the following,

  • Enter, edit and process claims for member as well as dependent
  • Should throw errors for invalid claims based on the incorrect data entered

Positive flow system testing should include scenarios to enter, edit and process claims for member as well as dependent

Negative flow system testing should include scenarios to

  • Enter and validate a claim with invalid diagnosis code and procedure code
  • Enter and validate a claim with inactive provider ID
  • Enter and validate a claim with terminated member

System integration testing should include scenarios to validate the feed to downstream systems such as finance and provider portal

Testing of Finance system:

Finance system should be capable of writing pay checks and making EFT payments to the respective recipient by processing the feeds from various upstream systems such as claims, member, provider and broker system.

Positive flow system testing should include scenarios to check whether correct address or account number is chosen for the respective provider, member or broker for the payment.

Negative flow system testing should include scenarios to

  • Check whether payment is done for invalid member, provider or broker ID by creating respective records in the feed
  • Check whether payment is done for invalid amount (Zero or negative) for the member, provider or broker by creating respective records in the feed

System integration testing is not needed as this doesn’t have any downstream systems and the feeds from the upstream are validated in the system integration testing of respective systems.

Testing of Member portal:

Member portal should be capable of the following,

  • View policy details and claim status
  • Make change requests in policy details
  • Make premium payments

Positive flow system testing should include scenarios to

  • Login and view policy details and claim status
  • Make change request to change address, name, phone number, etc.
  • Make premium payments

Negative flow system testing should include scenarios to

  • Login with invalid credentials
  • Make payment for a paid premium bill
  • Make payment with an invalid check

System integration testing is not needed as this doesn’t have any downstream systems and the feeds from the upstream systems are validated in the system integration testing of respective systems.

Testing of Provider portal:

Provider portal should be capable of the following,

  • View provider details, member details and claim status
  • Make change requests in provider details

Positive flow system testing should include scenarios to

  • Login and view provider details, member details and claim status
  • Make change request to change address, name, phone number, etc.

Negative flow system testing should include scenarios to

  • Login with invalid credentials
  • View member details with an invalid member ID

System integration testing is not needed as this doesn’t have any downstream systems and the feeds from the upstream system are validated in the system integration testing of respective systems.

Testing of Broker portal:

Broker portal should be capable of the following,

  • View broker details and commission payment
  • Make change requests in broker details

Positive flow system testing should include scenarios to

  • Login and view broker details and commission payment
  • Make change request to change address, name, phone number, etc.

Negative flow system testing should include scenarios to login with invalid credentials.

System integration testing is not needed as this doesn’t have any downstream systems and the feeds from the upstream are validated in the system integration testing of respective systems.

That’s it- that’s all the modules and the aspects we would test in them.

Important tips for Testing Healthcare software:

Tip#1. Dates are important and have to be accurate because a slight change in the date may cause a major defect to be un-noticed.

Tip#2. In healthcare, there are many test parameters such as different types of plan, members, providers, brokers, commission calculation method, etc., – so care should be taken while designing test cases by having a track of parameters covered and not covered.

Tip#3. Know the business users for the respective systems and think from their perspective to find any the best defects.

Tip#4. It is not needed to follow the same order for system testing and the scenarios provided here just cover the overall functionality of a healthcare application. You may also need to include some more scenarios (more hints at this and this post) based on the requirements you receive.

Tip#5. Health care is now moving towards cost-effective way of providing the care. Thus they have introduced exchange model where the subscriber can have a view of plans given by all the insurers which increases the competitive nature of the insurers thereby indirectly stating the need for cost reduction.  As healthcare evolves, there will be need for the change in software being used and there comes the revenue for IT by creation, modification and testing of software applications involved- which means we can anticipate more projects in this domain. So, keep a look out, if this interests you.

Tip#6. The key to succeed in health care application testing is claims – the complete knowledge of them and how they are adjudicated, etc.

Conclusion

Well, that covers the basics of healthcare domain and a way to test healthcare applications.

As testers, we know nothing is defect free. This article may also have some defects, if you find any defect or have a question please leave a comment. We welcome your valuable feedback on the article, as it will drive us towards excellence and improvement.

Wish you all the very best for your future endeavors as a healthcare tester. See you around!




Recommended reading

48 comments ↓

#1 Anjalim

this is a good guide to test health insurance systems. the scenarios are very detailed and useful.

thanks for sharing.

#2 Basheer

healthcare is evolving a lot with chance of many QA jobs in future like bfsi domain. so yes this article is a good starting point for all those.

#3 sumit

HI In your health care domain testing you did’t mention about HL7 , Hippa, dicom e.t.c those are standards for healthcare domain testing :(

#4 Subair K

Hi., I would like to the Standards which mentioned like dicom, hippa, HL7, etc.. Please include these in next part..

#5 Veda

Very nice one for everybody to know about Health care Domain….

#6 Sahil

Hi,
I have the same question as Sumit “In your health care domain testing you did’t mention about HL7 , Hippa, dicom e.t.c those are standards for healthcare domain testing”
Otherwise, it’s a great article.
Thanks

#7 Kedar

really useful thanks.

#8 Vairavan

@Sumit, Subair and Sahil
I agree that HIPAA, HL7, etc,. are standards that defines how data are entered, transferred and secured. the standards followed may affect the functionality of each system but does not have much impact on overall structure of health care application. The scenarios provided in this article are generic and can be applied to any standard since because these are basic scenarios.
Thanks.

#9 Vairavan

@Anjalim, Basheer, Veda and Kedar
Thanks for commenting.

#10 VISHAL M

I think when you are talking abt healthcare then its very unfair to be away from this topic like DICOM ,HL7 and RIS..
I have few articles to share as im working on this MEDICAL IMAGING domain from last 7 years.It will be very helpful for fresher’s…

Thanks…
VISHAL MESHRAM

#11 LiveKindLiveFair

Thank you again for a good article!

#12 Sheetal

comprehensive scenario list. good work.

#13 Madhu B

Hi VISHAL M
could you plz share those articles.

my id=madhubt1989@gmail.com

#14 Ravindra Sharma

Nice article on Healthcare !!
Could you please cover HIPAA Compliant messages, specifically 834 and 820. How can we test these messages ?

#15 Subhashini

I hope you can make something like this for Banking domain.. also i want to know more on FIX protocols and testing them

#16 VARUN SUNDAR

Really useful. Hope you continue this series with all kinds of domains in testing field..

#17 Rajat

Very NICE ARTICLE,,,,,
VISHAL M
Can you please forward your articale to rajgoyal00@gmail.com
I Will really appreciate all the help I can get,.
Thanks

#18 Ami Agrawal

These two articles are very helpful to beginners. I read both articles as i am also working in Healthcare Domain. I would like to ask you one question if you can explain it in detail and/or share specific link for that. My question is “What is Frontend Claim Testing and Backend Claim Testing in Healthcare? What is the testing Method for that if there is some different method?

#19 Mojmír N?me?ek

@VISHAL MESHRAM

I’d like to read your articles as well. I’m software developer working with HL7, RIS for 3 years.

Anything you have to say towards testing such systems might be valuable for me

#20 Dibakar Sahoo

I want to know the domain knowledge of Banking Application & work Flow of Banking Application . Can You Please Forward To my Mail ID dibakarsahoo50@gmail.com as son as possible.

#21 Jayshri

hi..
can anybody send me a sample test case for any application/website?
i want to learn how to write test cases.
my email is : patel.jayshri97@gmail.com

#22 Adarsh

This is good from Health Insurance which is only a part of Healthcare segment. Healthcare domain as such is vast and covers applications under various segments i.e., Healthcare Informatics, Healthcare Imaging, Healthcare Management systems, Healthcare Services, Healthcare Diagnostics, Healthcare Clinical systems, Healthcare Standards, etc..

#23 banu

VISHAL M
Can you please forward your articale to banuprasadd@gmail.com
I Will really appreciate all the help I can get,.
Thanks

#24 MOHANA KRISHNA

Is health care domain a right choice to start with? Most of the companies which I here for is based on bfsi domain. Please help me out. Athena health is hiring testing for health care.

#25 nani

thanks….very useful…

#26 gurpreet

Helpfull article.. Please write for home and motor insurance…

#27 Taru

Nice article on Healthcare !!
Could you please cover HIPAA Compliant messages, specifically 834 and 820. How can we test these messages ? test scenarios and test case for NO APTC and with APTC
Please email me at tarud93@yahoo.com
Diagram Highlighting Monthly Data Elements Required For Policy Purchased and No Financial
Assistance Requested – No APTC Calculated
Tax Filer 1. Name of tax filer 2. SSN of of tax filer 3. date of birth for tax filer 4. tax filer address.

#28 Anita

Hi Guys,
very helpful n deatiled!!!!
i am a begineer in DW testing.I need some real time project material like what type of data,hipaa 834 details ,test cases,some real time challenges faced in health insurance domain.Please send me on a.sharmanj@gmail.com

Thanks.

#29 Shajahan

I m working in a healthcare project now. This post is helped me a lot. Thanks a lot for the post.

#30 Shajahan

Can anybody send articals related to healthcare in my email sjahan11nov@gmail.com your cooperation will be highly appricated.Thanks in advance

#31 Shajahan

VISHAL M
Can you please forward your articale to sjahan11nov@gmail.com
I really appreciate your cooperation.

Thanks

#32 Manjushri

Can you please provide us a healthcare software to test..?
so we can test it and will get practical knowledge..

#33 Arpit

VISHAL M
Can you please forward your articale to shah_233@rediffmail.com
I really appreciate your cooperation.

Thanks

#34 Christy

Hi,
Good to read this, wanna get some idea DB testing procedures in Healthcare systems.
Ex: How Healthcare application DB testing differ from other application Back-end testing ect.

Please share the knowledge.. :)

Thanks in advance
Christy

#35 Snehal

Hi,
I was searching for Software testing career in healthcare domain. The information you provided is helpful.
Can you provide some details on software testing career if one has Biotechnology background ?

#36 K. Rao

Hi Vishal!

Very interesting article. Could you please share those articles. I am about to start my work for health care domain. Would be really helpful and appreciate your help..
Thanks in advance:)

#37 tulasi

Hi,the article is really very helpful.Thank u so very much for sharing.Actualli I am new to health care domain.So i want a sample project where i can write tescases and run the project which will be useful in mentioning project in my resume.Appreciate ur help if done as per my request.

#38 Venkat

What Kind of Tools or Applications are used for Maintaining all these Member, Claims, Finance, Broker Systems. Are there any famous Products in Market for these ??

#39 ani

Hi what is the difference between Member Portal and Member System?. Thanks

#40 priti

@ vishal M. can you pls also send me artical on health care. and pls provide some free project on health care.

#41 Soorya dharshini

@ vishal.
Hi Vishal, can you please send those articles to my mail ID. Am not into healthcare domain. Trying jobs in testing. So if u send me those articles it will be helpful.

#42 Soorya dharshini

@ Vishal,
mail id onyx.soorya@gmail.com

#43 Sharath

Hi Vishal, can you please send those articles to my mail ID. Am not into healthcare domain. Trying jobs in testing. So if u send me those articles it will be helpful.
From,
nanosharath@gmail.com

#44 farah

please can you send me or any one can help me about
health domain interview updated question and answere

farahyare321@gmail.com

#45 Joy

Hi Vishal,

Can you please share the articles related to HL7, HIPAA, DICOM etc for healthcare domain testing and mail id: gjyothirmayi@gmail.com.

I really appreciate your cooperation.

Thanks

#46 bhavani namala

Vishal M

Can you please share articles related to health care domain testing to my id.
Thanks for your help.

#47 randy

How should I handle the volume of testing? Meaning that one plan would typically have multiple test cases and with little mites resources testing all plan boundaries would be impossible, since the project I own has 5 k plans? Thx

#48 randy

How should I handle the volume of testing? Meaning that one plan would typically have multiple test cases and with few resources testing all plan boundaries would be impossible, since the project I own has 1 k+ plans . Automation considered but time is limited. team has 3 months to test. Coverage seems insurmountable

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