Financial Issues Chapter 15
DAW 8
Generic not available on the market
define and explain the difference between HMOs, POS & networks.
HMO- Costs are covered inside but not outside of the network POS- the patient's primary care physician must be a member and costs outside the network may be partially reimbursed. PPO- Costs outside the network may be partially reimbursed and the patient's primary care physician need not be member.
Preferred Provider Organization (PPO)
Health-care network that reimburses expenses outside the network at a lower rate than inside the network and usually requires generic substitution.
point of service (POS)
Health-care network where the patient's primary care physician must be a member and costs outside the network may be partially reimbursed.
HMO (health maintenance organization)
Health-care networks that usually do not cover expenses incurred outside the network and often require generic substitution.
online adjudication
Most prescription claims are now filed electronically by online claim submission and online processing the technician uses the computer to determine the exact coverage for each prescription with the appropriate third party.
refills
Most third-party plans require that most of the medication has been taken before the plan will cover a refill of the same medication.
DAW 6
N/A
medicare
National health insurance for people over the age of 65 or older, disabled people under the age of 65, and people with kidney failure.
DAW 0
No DAW
RX BIN Number
Number or code identifying where to send the claim
RX PCN number
Number or code identifying which company processes claims
DAW 2
Patient requested brand
Third- party programs
Another party besides the patient or the pharmacy that pays for some or all of the cost of medication: essentially, an insurer
Member ID
Unique number sometimes same as Social Security number
CPT code 99606
Used for followup encounters and may be billed in 1-15 min increments
CPT code
Used when filling out CMS 1550. These dentifiers areused for billing pharmacist- provided MTM services
Medicare—Part D Prescription Drug Coverage
What covers Medication Therapy Management?
rejected claims
When a claim is not accepted, the pharmacy technician can telephone the insurance plan's pharmacy help desk to determine if the patient is eligible for coverage.
dual co-pay
When a lower copay applies to generic drugs and a higher copay applies to brand drugs
dispensing code
When brand name drugs are dispensed, numbers corresponding to the reason for submitting the claim with brand name drugs are entered in a ______________ indicator field in the prescription system.
Group number
identifies the employer of the insured individual
CPT code 9905
used for first encounter with a pt and may be billed in 1-15 minute increments
DAW 9
"Other" override
DAW 4
- generic substitution permitted, but generic not in stock
list 10 common reasons for third-party claim rejection.
1) Dependent exceeds plan's age limit 2) Invalid birth date 3) Invalid person code 4) Invalid sex 5) Prescriber is not a network provider 6) Unable to connect with insurer's computer 7) Patient not covered (coverage terminated ) 8) Refill too soon 9) Refills not covered 10) NDC not covered
Pharmacy benefit manager
A company that administers drug benefit programs for insurance companies, HMOs and self- insured employers
medicaid
A federal-state program for the needy
TRICARE
A government health program that serves dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members; formerly called CHAMPUS.
POS
A network of providers where the patient's primary care physician must be a member and costs outside the network may be partially reimbursed.
CPT 99607
An add on code to be used with 99605 or 99606 when additional 15 minute increments are spent
prior authorization
A requirement that your physician obtain approval from your health insurance plan to prescribe a specific medication for you. It is a technique for minimizing costs, wherein benefits are only paid if the medical care has been pre-approved by the insurance company.
deductible
A set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses.
Card issuer ID
A unique identifier for the health plan
prescription drug card
BIN, Plan code, Group code, Issuer, ID, Subscriber name, PCP, Copays, Help desk telephone number, DAW codes
DAW 5
Brand dispensed, priced as generic
prescription drug benefit
Cards that contain necessary billing information for pharmacies, including the patient's identification number, group number, and co-pay amount.
workers' compensation
Coverage for employees accidentally injured on the job.
CPT
Current Procedural Terminology
DAW 1
DAW handwritten on the prescription by the prescriber
co-insurance
Essentially an agreement between the insurer and the insured to share costs
Days Supply
Insurance plans have set limits for how much of a med can be dispensed atlast.
maintenance medications
Many managed care health programs require mail order pharmacies to fill prescriptions for maintenance medications
age limitations
Many prescription drug plans have age limitations for children or dependents of the cardholder.
Medication Therapy Management (MTM)
Medicare recipients that are taking multiple meds or have certain diseases get this service from Pharmacists. It is billed by the tech.
DAW 3
Pharmacist selected brand
coordination of benefits
Process to provide maximum coverage for health benefits when a patient has coverage by two plans.
DAw 7
Substitution not allowed - brand drug mandated by law
usual and customary (U&C) or Usual, customary, reasonable price
The MAC is often determined by survey of the ______________________ prices for a prescription within a given geographic area. This is also referred to as the _________________________ price for the prescription.
maximum allowable cost
The amount paid by the insurer is not equal to the retail price normally charged, but is determined by a formula described in a contract between the insurer and the pharmacy. The amount paid by the insurer is called.....
CMS 10114
The from used for providers to apply for a NPI number
patient identification number
The number assigned to the patient by the insurer that is indicated on the drug benefit card. If it does not match the code for the patient in the insurer's computer (with the same sex and other information) a claim may be rejected.
co-pay
The portion of the cost of prescriptions that patients with third-party insurance must pay
Prescription drug plans
Third party programs for medicare part D
formulary
a list of medications approved for use
Universal claim form
a standard claim form accepted by many insurers
tier
categories of medications that are covered by third party plans
patient assistance programs
programs offered by some pharmaceutical manufacturers to help need.
NPI
the code assigned to recognized health care providers, needed to bill MTM services
CMS-1500 Form
the standard form used by health-care providers to bill for services