14 - Financial Issues

Question 1

a company that administers drug benefit programs for insurance companies, HMOs, and self-insured employees

Answer 1

pharmacy benefit manager

Question 2

the maximum amount of payment for a given prescription, determined by the insurer to be a usual and customary price

Answer 2

usual & customary (U&C)

Question 3

health-care networks that usually do not cover expenses incurred outside the network and generally require generics

Answer 3

HMO

Question 4

health-care network where the patient’s primary care physician must be a member and costs outside the network mat be partially reimbursed (TCF)

Answer 4

POS

Question 5

health-care network that reimburses expenses outside the network at a lower rate than inside the network and usually requires generics

Answer 5

PPO

Question 6

health-care providers use this form to bill for services

Answer 6

CMS-1500

Question 7

form used by health0care providers to apply for an NPI

Answer 7

CMS-10114