Financial Issues

A network of providers for which costs are covered inside but not outside of the network.

HMO

The code assigned to recognize health care providers; needed to bill MTMS.

National Provider Identifier (NPI)

A network of providers where the patient's primary care physician must be a member and costs outside the network may be partially reimbursed.

POS

A network of providers where costs outside the network may be partially reimbursed and the patient's primary care physician need not be a member.

PPO

The maximum amount of payment for a given prescription, determined by the insurer to be a reasonable price.

U&C or UCR

Co-pays that have two prices: one for generic and one for brand medications.

dual co-pay

True or false: All Medicaid programs have an open formulary.

false

True or false: The amount paid by a co-insurer to the pharmacy is equal to the wholesale price of a drug.

false

A list of medications covered by third party plans.

formulary

True or false: The CPT code for billing and initial patient encounter for pharmacist-provided services is 99605.

true

A standard claim form accepted by many insurers.

universal claim form (UCF)

An employer compensation program for employees accidentally injured on the job.

workers' compensation

True or false: Many third-party programs have drug formularies.

true

Why is important to know the benefits of various third party programs?

...

The standard form used by health care providers to apply for a National Provider Identifier (NPI). This six-page form, page one of which is shown below, is available by calling the EPI Enumerator.

CMS-10114 form

The standard form used by health care providers, such as physicians, to bill for services. It can be used to bill for disease state management services.

CMS-1500 (formerly HCFA 1500) form

Identifiers used for billing pharmacist-provided MTMS.

CPT code

Identifiers used for billing pharmacist-provided MTM services.

Current Procedural Terminology (CPT Codes)

A federal-state program, administered by the states, providing health care for the needy.

Medicaid

A federal program providing health care to people with certain disabilities or who are over age 65; it includes basic hospital insurance, voluntary medical insurance, and voluntary prescription drug insurance.

Medicare

Services provided to some Medicare beneficiaries who are enrolled in Medicare Part D and who are taking multiple medications or have certain diseases.

Medication Therapy Management Services (MTMS)

Third party programs for Medicare Part D.

Prescription Drug Plans (PDPs)

If an online claim is rejected, why is it important to review the information that was originally entered before calling?

To verify that it was not entered incorrectly.

_____ services are provided by pharmacists to some patients enrolled in Medicare Part D. a. MTM b. PDP c. CPT d. NPI

a. MTM

_____ is a federal-state program, administered by states, providing health care for the needy. a. Medicaid b. HMO c. Medicare d. PPO

a. Medicaid

A(an) _____ is a network of providers where costs outside the network may be partially reimbursed and the patient's primary care physician need not be a member. a. PPO b. HMO c. POS d. MAC

a. PPO

A drug formulary is a. a list of medication that are covered by a third party program. b. an official compendium of the FDA. c. a listing of the ingredients in a prescription. d. the price of a prescription under a third party program.

a. a list of medication that are covered by a third party program.

Plans in which the patient pays a different around depending on whether a generic or brand name medication is dispensed have a. dual co-pays. b. MAC. c. duplicate pricing. d. UCR.

a. dual co-pays.

The Maximum Allowable Cost (MAC) is usually _____ the Usual and Customary (U&C) price. a. less than b. greater than c. equal to

a. less than

Companies that administer drug benefit programs are called a. pharmacy benefit managers. b. MACs. c. HMOs. d. employers.

a. pharmacy benefit managers.

When there is a question on insurance coverage for an online claim, the pharmacy technician can a. telephone the insurance plan's pharmacy help desk. b. immediately refer the problem to the pharmacist.

a. telephone the insurance plan's pharmacy help desk.

When a technician receives a rejected claim "NDC Not Covered,' this probably means a. the insurance plan has a closed formulary. b. the insurance plan has an open formulary. c. the birth date submitted does not match the birth date in the insurer's computer. d. the patient has mail order.

a. the insurance plan has a closed formulary.

Another party, besides the patient or the pharmacy, that pays some or all the cost of the medication is a(an) a. third party. b. co-insurance. c. MAC. d. UCR.

a. third party.

The form used by health care providers to apply for a National Provider Identifier (NPI) is a. CMS-1500. b. CMS-10114. c. a universal claim form. d. CPT 0116T.

b. CMS-10114.

A(an) _____ is a network or providers for which costs are covered inside, but not outside of the network. a. POS b. HMO c. MAC d. PPO

b. HMO

A(an) _____ is a network of providers where the patient's primary care physician must be a member and costs outside the network may be partially reimbursed. a. HMO b. POS c. PPO d. MAC

b. POS

Which type of managed care program is least likely to require generic substitution? a. Medicare b. PPO c. Medicaid d. HMO

b. PPO

The portion of the price of the medication that the patient is required to pay is called the a. co-insurance. b. co-pay. c. maximum allowable cost. d. Uusal and customary price.

b. co-pay.

If a third party plan has a dual co-pay, the patient usually pays _____ for generic drugs compared to brand name drugs. a. the same amount b. less c. more

b. less

HMOs, POS, and PPOs are examples of a. co-insurance. b. managed care programs. c. MAC. d. co-pays.

b. managed care programs.

The resolution of prescription coverage for a prescription through the communication of the pharmacy computer with the third party computer is called a. PBM. b. online ajudication. c. MAC. d. UCR.

b. online adjudication.

Which of the following information is generally not required in online claim processing? a. birth date b. weight c. sex d. group number

b. weight

The DAW indicator that is appropriate for online adjudication if a physician has handwritten DAW on the prescription is a. 4. b. 2. c. 1. d. 3.

c. 1.

An agreement for cost-sharing between the insurer and the insured is called a. MAC. b. dual co-pay. c. co-insurance. d. co-pay.

c. co-insurance.

When a technician receives a rejected claim "invalid birth date," this probably means a. the patient has Medicaid. b. the patient does not have coverage. c. the birth date submitted by the pharmacy does not match the birth date in the insurer's computer. d. the patient has Medicare.

c. the birth date submitted by the pharmacy does not match the birth date in the insurer's computer.

When a technician receives a rejected claim "Unable to Connect," this probably means a. the insurer has an incorrect birth date for the patient. b. the patient's coverage has expired. c. the connection with the insurer's computer is temporarily unavailable due to computer problems. d. the insurer has a closed formulary.

c. the connection with the insurer's computer is temporarily unavailable due to computer problems.

When a technician receives a rejected claim "Invalid Person Code," this probably means a. the patient is on Medicare b. the patient has a mail order program. c. the person code entered does not match the birth date and/or sex in the insurer's computer problems. d. the patient is on Medicaid.

c. the person code entered does not match the birth date and/or sex in the insurer's computer program.

An agreement for cost-sharing between the insurer and the insured.

co-insurance

The portion of the price of medication that the patient is required to pay.

co-pay

The CPT Codes for billing Medication Therapy Management Services provided by pharmacists are a. ICD-9. b. MAC. c. PPO. d. 99605, 99606, and 99607.

d. 99605, 99606, and 99607.

A standard form used by healthcare providers to bill for services is a. a universal claim form (UCF). b. a pdf. c. an NDC. d. CMS-1500.

d. CMS-1500..

_____ is a program for people over 65 or with certain disabilities. a. Medicaid b. ADC c. Workers' Compensation d. Medicare

d. Medicare

The optional Medicare program with prescription drug coverage is a. Medicare Part A. b. Medicare Part B. c. Medicare Part C. d. Medicare Part D.

d. Medicare Part D.

Procedures for billing compounded prescriptions a. should always be referred to the pharmacist. b. are not available. c. do not apply in community pharmacy practice. d. are variable, depending on the insurer or PBM.

d. are variable, depending on the insurer or PBM.

A(an) _____ is a set amount that must be paid by the patient before the insurer will cover additional expenses. a. co-insurance b. co-pay c. maximum allowable cost d. deductible

d. deductible

Pharmacies receive payment from third parties equal to a. the retail price of the drug. b. the manufacturer's cost. c. a wholesaler's price. d. none of the above.

d. none of the above.

Patient assistance programs are offered by a. HMOs. b. pharmacies. c. physicians. d. pharmaceutical manufacturers.

d. pharmaceutical manufacturers.

Closed formulary programs, such as Medicaid, may cover drugs that are not on the formulary through a process called a. dual co-pay. b. co-insurance. c. POS d. prior authorization.

d. prior authorization.

A set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses.

deductible

The maximum price per tablet (or other dispensing unit) an insurer or PBM will pay for a given product.

maximum allowable cost (MAC)

The resolution of prescription coverage through the communication of the pharmacy computer with the third party computer.

online adjudication

Manufacturer sponsored prescription drug programs for the needy.

patient assistant programs

Companies that administer drug benefit programs.

pharmacy benefit managers

Cards that contain third party billing information for prescription drug purchases.

prescription drug benefit cards

Categories of medications that are covered by third party plans.

tier

True or false: A dual co-pay means that the patient will pay a different co-pay for generic and brand names.

true

True or false: A pharmacy benefits manager is a company that administers drug benefits programs.

true

True or false: An NPI number identifies the pharmacy.

true

True or false: In online adjudication, the claim processing computer determines if the claim is valid and what the co-pay should be, usually in less than a minute.

true