billing And Reimbursement (Module 3)

Question 1

Process in which a medical provider approves medical necessity of a medication or a service to an insurance company
Use for medical and pharmacy claim
Act as a safety and cost-saving measure
May also be referred to as a PA, pre-certification, prior approval or predetermination.

Answer 1

What is a prior authorization?

Question 2

A collection of treatment review and cost reduction techniques used by health insurance and help plans

Answer 2

Drug. Utilization management or
Drug utilization review

Question 3

A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefit. Also call a drug list.

Answer 3

Drug formulary

Question 4

The process of determining which of two or more insurance policies will have the primary responsibility of paying a claim and the Exten, to which the other policies will contribute

Answer 4

COB (coordination of benefits)

Question 5

A collection of treatment review and cost reduction techniques used by health issuers and health plans

Answer 5

Drug utilization management
Drug ultization Review

Question 6

The process of determining, which of the two or more insurance policies, will have the primary responsibility of paying a claim, or extend to which the other policy will contribute

Answer 6

COB (coordination of benefits)

Question 7

 Doctor needs to prove what diease or condition or coding condition that he prescribed for treatment for

Answer 7

ICD - 10 diagnosis

Question 8

J - code

Answer 8

Its a type of injection , medication that he or she cannot injection administration, and for chemotherapy,

Question 9

Sometimes referred to, as a healthcare system is the organization of people, institution, and resources that deliver healthcare service to meet the health needs of target population

Answer 9

A health systems

Question 10

How’s Novolin package?

Answer 10

Novolin R comes in:
10 ML vials (small bottles) for use with syringe
-3 Ml Penfill cartridge for use with Novo Nordisk insulin delivery devices that work with the three ML PenFill cartridge and NovoFine dispose of needles. The cartridge deliver device can be used with a Novopen 3 penmate
- 3 ml Innollet prefilled insulin  syringe

Question 11

It is a seven-character, alphanumeric code.
Each code begins with a letter, and that letter is followed by two numbers.
The first three characters of ICD-10-CM (example :E10.9 )r the category.
The category describes the general type of injury or disease.
The category is followed by a decimal point and the sub category.
This is followed by up to sub classifications, which further explain the cost, manifestation, location, and severity, and type of injury or disease. The last character is the extension

Answer 11

And ICD-10 code
Example: ICD-10: E10.9 or E11.8

Question 12

True out of pocket

Answer 12

TrOOP

Question 13

Benefits, coordination and recovery center

Answer 13

BCRC

Question 14

RDS

Answer 14

Retire, drug subsidy

Question 15

What is 34B discount agreements call?

Answer 15

Pharmaceutical pricing agreement.
Manufacture agree to a pond discount on a drug so specified provider.
Specified provider are referred to as covered entity.

Question 16

Lowest co-pay, usually generic drug, preferred

Answer 16

Tier 1

Question 17

Higher copay, can be non-preferred generic, or preferred brand

Answer 17

Tier 2

Question 18

Highest co-pay, usually drugs that are non-preferred brand or DAW brands with a generic 

Answer 18

 Tier 3

Question 19

Speciallty drug that usually require a PA , could be a co-pay charge, or a percentage of the cost 

Answer 19

Tier 4

Question 20

Information need to submit PA request:

Answer 20

Member (patient) demographics
prescriber name and contact information.
Prescriber NPI and/or DEA number
Drug information ( name, dose & sig)
I CD 10 diagnose (Rx) code
J code.
Previous try and fail medication.
Allergies
Anticipated length of therapy.
Any additional pertinent clinical information?
Pharmacy, NPI, and or DEA number (specific circumstances, example substance drug)

Question 21

(Facility)Submitting a prior authorization

Answer 21

—medication PA requested typically begin at the pharmacy
— medical PA requested are handled with the billing office at a healthcare system

Question 22

Process of submitting a prior authorization:

Answer 22

1-when a clam, it’s rejected at the pharmacy, prescribers Office is notified by fax
2-the prescriber or designating staff member will fill out the PA request form with all the necessary information and submit to the health insurance PA Department for review
3-the PA department will review the prioritization and either approve or deny or request additional information before making a final decision.
4– for there is a possibility that or if you are or suggest another medication or dose to be used. They can also approve the PA, but with limitation.
5– If the PA has been approved special codes will be added to the members profile to allow the claim to successfully process at the pharmacy.
6– the insurance company will notify the prescriber decision, appeal process information and any other options they have, if they are not satisfied with the decision.

Question 23

A process in which an insured promotes use of a preferred, less -costly medication with the same therapeutic class prior to approving a non-preferred, more expensive medication.

Answer 23

STEP THERAPY

Question 24

Third-party prior authorization, rejection, troubleshooting, and resolution
Why/who can do the P)/ type of claims; who approves PA

Answer 24

1– Third party prior authorization companies are typically used to save time and reduced cost for the insurance provider.

2– they are typically staffed with physicians, Pharmacist, pharmacy, technicians, and nurse.

3– the different claims they review can be for medical procedure, workers, compensation, medical devices, or pharmacy claims.

4– utilization management review can I sell completed by the party prior authorization companies.

Question 25

Common third-party prioritization Rejection troubleshooting , and resolution

Answer 25

1– common rejection issues that can be resolved at the pharmacy are COB , NDC, mismatched, and day supply.
2– once the pharmacy has on, necessarily payor information in the system, they can typically adjust the billing sequence in the billing system to accurately bill, Medicare, and all other pairs.
3– some insurance companies will cover a medication, but it is limited to specific NDC’s.
4– also, some insurance plans will cover a medication only up to certain day supply.
** in this situation, a PA or override isn’t typically necessary, unless they are special circumstances.