PhT 140 - Lab 12: Processing Third-Party Claims

Each of the following person codes is matched with the person described by the code, except one. Which of the pairs does not match?

01: an only child

A "patient not covered" rejection from an insurance company could mean

All of the answers are correct.

A "refill too soon" rejection from an insurance company could mean

All of the answers are correct.

Not all insurance carriers require all the same information on a claim, but most of them do require

All of the answers are correct.

The abbreviation DUR stands for

Drug Utilization Review.

Which of the following statements about third-party adjudication is true?

It is a bigger part of a community pharmacy technician's job than a hospital pharmacy technician's job.

Which of the following are some of the common replies from an insurance company on a third-party adjudication?

NDC not covered, patient not covered, and refill too soon

What does the third-party insurance rejection phrase "NDC not covered" mean?

The drug the pharmacy ordered for the patient is not covered by the patient's health insurance.

What should a pharmacy technician do upon receiving a NDC not covered rejection?

They should look at all the information the insurance company sent-it may contain information about alternative medications or brands of the same medication that are covered by the insurance company. If it does, hand that information off to the pharmacist.

A "refill too soon" rejection from an insurance company could mean the patient has run out of medication sooner than the insurance company expected based on the amount of medication the patient is supposed to be taking daily. When this type of rejection occurs, a pharmacy technician should

Two of these answers are correct.

Some strategies for dealing with angry patients include

Two of these answers are correct.

In community pharmacy, technicians spend _____ on the phone trying to resolve problems with insurance companies.

a lot of time

The third party in a third-party claim is

an insurance company.

A "patient not covered" rejection from an insurance company could mean that the patient has recently changed insurance companies. If that is the case, the pharmacy technician should

ask for the patient's insurance card, make a copy of it, then enter that new insurance information in the pharmacy computer, then resubmit the claim to the new insurance company.

In a pharmacy, successfully submitting a claim to an insurance company and obtaining payment for it is called

capturing.

When a patient becomes angry about the rejection of an insurance claim, it is considered a best practice to

hand off the problem to a pharmacist or a more experienced technician.

If a drug is not covered, you should

inform the patient, and let the patient know about his or her options.

Upon receiving "patient not covered" rejection, a pharmacy technician should

investigate further-double check the accuracy of the patient's information in the computer, and ask if the patient has had any recent changes in coverage, then call the insurance company to verify coverage.

Some pharmacy software programs are case-sensitive, which means

it matters whether you capitalize the letters of words.

It's a best practice to

keep patients up to date on the status of their prescriptions.

It is understandable that many patients get frustrated with their prescription drug insurance, because

many patients have the impression that their doctors and pharmacists have detailed knowledge about what is covered in their insurance plan, but they don't.

If one drug is not covered by an insurance company but an alternative exists, the _____ must contact the prescriber to find out whether the prescriber would like to prescribe the alternative. In that case, the pharmacist technician should _____.

pharmacist / tell the patient that the pharmacist has to contact the doctor, and that it may take some time.

In a pharmacy context, the definition of capturing is

successfully submitting a claim to an insurance company and obtaining payment for it.

In the hospital setting, third-party adjudication is dealt with by _____ rather than by _____.

the billing department / pharmacy technicians

Third-party adjudication is

what happens when a pharmacy submits a patient's prescription insurance claim to an insurance company and the insurance company decides how much to pay for that claim.