Billing and Reimbursement Flashcards
What company focuses on the pharmacy services provided under a health care plan?
Pharmacy Benefit Management Company
What word means paying a fixed prepaid fee per person to provide a range of health services; paid before services are provided?
Capitation
What is a set fee paid for each type of service that is performed and is paid at the time of service?
Fee for service
What is a care provider where the primary care physician directs all medical care for patient, a proactive instead of reactive health care and the goal of it is to keep patient healthy?
Health Maintenance Organizations (HMO)
What care provider provides provides health care services at a discounted fee for services. and insurance pays a percentage of the bill?
Preferred Provider Organizations (PPO)
What care provider allows you to choose between HMO and PPO for services, direct medical care is the primary care provider (PCP), and members can see out-of-network providers but at a higher cost and premium.
Point of service plans (POS)
What is a hybrid of PPO, but does not make payments to an outside provider?
Exclusive Point of Service (EPOS)
What are financial accounts that are established by an individual or family t pay for qualified medical expenses?
Health savings account
What plan is it when a patient obtains a patient drug card from a pharmacy benefits manager and are very expensive?
Private plans
Who can use medicare?
They are for people 65 years or older NOT based on income
How many parts of medicare are there and what do they cover?
There are four parts.
- Part A covers inpatient care like hospice and the hospital.
- Part B covers outpatient care like physical therapy
- Part C offers alternate way to get benefits for Part A or B through PPO or HMO at a high price
- Part D: provides prescription drug coverage like insulin and vaccines
Who uses Medicaid?
Medicaid is controlled by the federal and state as a program based on income
What is AWP and what is it?
It stands for average wholesale price.
-it is the average price wholesalers sell medication
What does AAC stand for and what is it?
It stands for actual acquisition cost.
It is the actual cost the pharmacy paid for medication
What does MAC stand for and what is it?
It stands for max allowed cost.
It is determined by managed care organizations
What does formulary usage mean?
it is a list medications approved for use or reimbursement under prescription plan
What is a open formulary?
a list of medications where a variety of drugs are available
What is a close formulary?
A list of medications which limits access of a practitioner to some medication
What is a restricted formulary?
where selective drugs are available
What is the formulary exception process?
It is the right to use formulary and nonformulary medication to be dispensed
What is a formulary override?
It is the process that requires physician to request for approval to prescribe a nonformulary medication and document reason for the medication
What is Prior authorization?
when the phycisian obtains approval form the health insurance plan to prescribe a specific medication for you
List the information contained in a prescription drug card
- BIN (bank identification number)
- Plan code
- Issuer
- ID
- subscriber name
- copays
- help desk telephone number
- DAW codes
What does DAW 0 mean?
no production selection is indicated
What does DAW 1 mean?
substitution not allowed by prescriber
What does DAW 2 mean?
substitution is allowed and that the patient requested product dispensed
What does DAW 3 mean?
substitution is allowed, and the pharmacist selected the product dispensed
What does DAW 4 mean?
substitution is allowed, but generic is not in stock
What does DAW 5 mean?
substitution is allowed and brand name is dispensed as generic
What does DAW 6 mean?
Override
What does DAW 7 mean?
substitution is not allowed and drug is mandated by law
What does DAW 8 mean?
substitution is allowed, but generic is not available in marketplace
What does DAW 9 mean?
other
What does rejection code 1 mean?
invalid BIN
What does rejection code 2 mean?
invalid version number
What does rejection code 3 mean?
invalid transaction code
What does rejection code 4 mean?
invalid processor control number
What does rejection code 5 mean?
invalid pharmacy number
What does rejection code 6 mean?
invalid group number
What does rejection code 7 mean?
invalid card holder number
What does rejection code 8 mean?
invalid person code
What does rejection code 9 mean?
invalid birth date
What does rejection code 10 mean?
invalid gender code
What does rejection code 11 mean?
invalid patient relationship
What does rejection code 15 mean?
invalid date of service
What does rejection code 16 mean?
invalid prescription/ service reference number
What does rejection code 19 mean?
invalid days supply
What does rejection code 20 mean?
invalid compound code
What does rejection code 22 mean?
invalid DAW/ product selection code
What does rejection code 25 mean?
invalid prescriber number
What does rejection code 26 mean?
invalid unit of measure
What does rejection code 28 mean?
invalid date prescription written
What does rejection code 29 mean?
invalid number of refills authorized
What is health care reimbursement service that is created by CMS (center for medicare and medicaid service) that created a list of drugs covered by health insurance
Ambulatory care parenteral therapy
What is Cognitive service?
pharmacists authority to prescribe a certain drug and intervention for it
What is community care reimbursement?
the cost of medications and dispense fee for monitoring dispensing and reward keeping
What is long term care reimbursement?
per diem reimbursement based on prior medications purchased
What is the formula for inventory turnover rate?
annual dollar purchase/ average inventory value
What is the formula for net profit?
overall cost* desired percent profit
What is an overhead?
sum of all expenses
