Billing and Reimbursement Flashcards

1
Q

What company focuses on the pharmacy services provided under a health care plan?

A

Pharmacy Benefit Management Company

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2
Q

What word means paying a fixed prepaid fee per person to provide a range of health services; paid before services are provided?

A

Capitation

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3
Q

What is a set fee paid for each type of service that is performed and is paid at the time of service?

A

Fee for service

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4
Q

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?

A

Health Maintenance Organizations (HMO)

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5
Q

What care provider provides provides health care services at a discounted fee for services. and insurance pays a percentage of the bill?

A

Preferred Provider Organizations (PPO)

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6
Q

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.

A

Point of service plans (POS)

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7
Q

What is a hybrid of PPO, but does not make payments to an outside provider?

A

Exclusive Point of Service (EPOS)

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8
Q

What are financial accounts that are established by an individual or family t pay for qualified medical expenses?

A

Health savings account

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9
Q

What plan is it when a patient obtains a patient drug card from a pharmacy benefits manager and are very expensive?

A

Private plans

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10
Q

Who can use medicare?

A

They are for people 65 years or older NOT based on income

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11
Q

How many parts of medicare are there and what do they cover?

A

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
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12
Q

Who uses Medicaid?

A

Medicaid is controlled by the federal and state as a program based on income

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13
Q

What is AWP and what is it?

A

It stands for average wholesale price.

-it is the average price wholesalers sell medication

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14
Q

What does AAC stand for and what is it?

A

It stands for actual acquisition cost.

It is the actual cost the pharmacy paid for medication

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15
Q

What does MAC stand for and what is it?

A

It stands for max allowed cost.

It is determined by managed care organizations

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16
Q

What does formulary usage mean?

A

it is a list medications approved for use or reimbursement under prescription plan

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17
Q

What is a open formulary?

A

a list of medications where a variety of drugs are available

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18
Q

What is a close formulary?

A

A list of medications which limits access of a practitioner to some medication

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19
Q

What is a restricted formulary?

A

where selective drugs are available

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20
Q

What is the formulary exception process?

A

It is the right to use formulary and nonformulary medication to be dispensed

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21
Q

What is a formulary override?

A

It is the process that requires physician to request for approval to prescribe a nonformulary medication and document reason for the medication

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22
Q

What is Prior authorization?

A

when the phycisian obtains approval form the health insurance plan to prescribe a specific medication for you

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23
Q

List the information contained in a prescription drug card

A
  • BIN (bank identification number)
  • Plan code
  • Issuer
  • ID
  • subscriber name
  • copays
  • help desk telephone number
  • DAW codes
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24
Q

What does DAW 0 mean?

A

no production selection is indicated

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25
Q

What does DAW 1 mean?

A

substitution not allowed by prescriber

26
Q

What does DAW 2 mean?

A

substitution is allowed and that the patient requested product dispensed

27
Q

What does DAW 3 mean?

A

substitution is allowed, and the pharmacist selected the product dispensed

28
Q

What does DAW 4 mean?

A

substitution is allowed, but generic is not in stock

29
Q

What does DAW 5 mean?

A

substitution is allowed and brand name is dispensed as generic

30
Q

What does DAW 6 mean?

A

Override

31
Q

What does DAW 7 mean?

A

substitution is not allowed and drug is mandated by law

32
Q

What does DAW 8 mean?

A

substitution is allowed, but generic is not available in marketplace

33
Q

What does DAW 9 mean?

A

other

34
Q

What does rejection code 1 mean?

A

invalid BIN

35
Q

What does rejection code 2 mean?

A

invalid version number

36
Q

What does rejection code 3 mean?

A

invalid transaction code

37
Q

What does rejection code 4 mean?

A

invalid processor control number

38
Q

What does rejection code 5 mean?

A

invalid pharmacy number

39
Q

What does rejection code 6 mean?

A

invalid group number

40
Q

What does rejection code 7 mean?

A

invalid card holder number

41
Q

What does rejection code 8 mean?

A

invalid person code

42
Q

What does rejection code 9 mean?

A

invalid birth date

43
Q

What does rejection code 10 mean?

A

invalid gender code

44
Q

What does rejection code 11 mean?

A

invalid patient relationship

45
Q

What does rejection code 15 mean?

A

invalid date of service

46
Q

What does rejection code 16 mean?

A

invalid prescription/ service reference number

47
Q

What does rejection code 19 mean?

A

invalid days supply

48
Q

What does rejection code 20 mean?

A

invalid compound code

49
Q

What does rejection code 22 mean?

A

invalid DAW/ product selection code

50
Q

What does rejection code 25 mean?

A

invalid prescriber number

51
Q

What does rejection code 26 mean?

A

invalid unit of measure

52
Q

What does rejection code 28 mean?

A

invalid date prescription written

53
Q

What does rejection code 29 mean?

A

invalid number of refills authorized

54
Q

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

A

Ambulatory care parenteral therapy

55
Q

What is Cognitive service?

A

pharmacists authority to prescribe a certain drug and intervention for it

56
Q

What is community care reimbursement?

A

the cost of medications and dispense fee for monitoring dispensing and reward keeping

57
Q

What is long term care reimbursement?

A

per diem reimbursement based on prior medications purchased

58
Q

What is the formula for inventory turnover rate?

A

annual dollar purchase/ average inventory value

59
Q

What is the formula for net profit?

A

overall cost* desired percent profit

60
Q

What is an overhead?

A

sum of all expenses