Healthcare Data Reference Guides
In-depth technical documentation covering NPI, ICD-10, CPT codes, dispensing standards, and more. Production-ready database schemas, code examples, and best practices.
Showing 19-24 of 31 guides
Medicare & Medicaid: Payer Data Models
Medicare and Medicaid database schemas, eligibility verification, and claims processing.
HEDIS Measures: Quality Metrics & Reporting
HEDIS quality metrics, measure calculation, numerator/denominator logic, and Star Ratings.
Prior Authorization: Approval Workflow & Database
Prior authorization workflow, database schema, payer integration, and denial management.
Claims Adjudication: Processing & Payment Logic
Claims adjudication engine, payment calculation, denial codes, and automated processing.
HCC Risk Adjustment: Hierarchical Condition Categories
HCC coding, RAF score calculation, Medicare Advantage risk adjustment, and CMS-HCC database.
Pharmacy Benefits (PBM): Formulary Management
PBM systems, formulary database, drug tiers, rebates, and pharmacy claims adjudication.
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