PTCB - Pharmacy Billing and Reimbursement

insurance premium

when an insurance company charges an individual to maintain their insurance coverage

Prior Authorization

when an insurance company requires a prescriber to state why they ordered a particular drug for a patient before the insurance company will cover the drug.

Medicaid

a federal program based on income as well as other circumstances. eligibility is determined on a month by month basis. it generally covers doctors visits, emergency care, hospital care, vaccinations, prescriptions, vision, hearing, and preventative care for children

medicare part A

a federally funded health care program that pays for a patient's inpatient hospital care, skilled nursing care, hospice care, and home health care

medicare part B

a federally funded health care program that provides a patient with coverage for physician visits, outpatient care, physical therapy, and occupational therapy.

medicare part D

a federally funded health care program that provides a patient with coverage for select prescription medications, medical supplies, insulin, and vaccinations.

formulary

a list of medications approved for use or reimbursement under a prescription plan.

restricted formulary

a selective, limited, partially closed formulary in which some non-formulary medications are available.

Bank Identification Number

a six digit number used to ID the company that will reimburse the pharmacy for the prescription being filled

National Provider Identifier

a unique number assigned to health care provider, to transmit health information according to the HIPAA

open formulary

a variety of several medications in each therapeutic classification

closed formulary

a very limited number of medications available in each therapeutic classification, and sometimes no medications in certain classifications.

actual acquisition cost

actual cost a pharmacy paid for a medication

medicare advantage (medicare part C)

allows participants in Medicare Part A and B to obtain coverage through a Health Maintenance Organization or Preferred Provider Organization that provides additional services at a higher cost.

DAW 9

code used as an "other" override

DAW 6

code used as an all purpose dispense as written override

DAW 2

code used when a patient requests a brand name product to be dispensed

DAW 3

code used when a pharmacist requests a brand name product to be dispensed

DAW 4

code used when a pharmacy does not have a generic drug in stock and dispenses the brand name product instead

DAW 1

code used when a prescriber request a brand name product to be dispensed

DAW 0

code used when the prescriber allows the generic form to be dispensed

DAW 8

code used when the prescriber allows the generic form to be dispensed, but the generic form is not available on the market

DAW 7

code used when the prescriber allows the generic form to be dispensed, but the law requires the brand form to be dispensed

DAW 5

code used when the prescriber allows the generic from to be dispensed but the pharmacy dispenses the brand form as the generic form.

plan code

denotes the prescription provider

Health Maintenance Organizations

focus on keeping their patients healthy by providing small co-pays and minimal to no deductibles.

identification number

given to a patient so that their insurance coverage can be authorized by a pharmacy

Preferred Provider Organizations

offer health care services for a discounted fee by using non-exclusive contracts with network providers.

Drug Topics Red Book

online resource listing the updated average wholesale price of all drugs

Point of Service Plans

require their patient to use their primary care physicians to direct their medical care but allow its members to see out of network providers at a higher cost.

group code

shows the patient's employer

average wholesale price

the average price that wholesalers sell a medication

issuer

the health insurance company who issued the insurance card.

online adjudication

the process by which a pharmacy submits prescription claims electronically to a third party provider when filling a prescription to ensure accurate copayments and timely payment. it allows the pharmacy to verify a patient's eligibility and to determine the plan name, patient identification, and group number from Medicare.