billing And Reimbursement (Module 3) Flashcards
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.
What is a prior authorization?
A collection of treatment review and cost reduction techniques used by health insurance and help plans
Drug. Utilization management or
Drug utilization review
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefit. Also call a drug list.
Drug formulary
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
COB (coordination of benefits)
A collection of treatment review and cost reduction techniques used by health issuers and health plans
Drug utilization management
Drug ultization Review
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
COB (coordination of benefits)
 Doctor needs to prove what diease or condition or coding condition that he prescribed for treatment for
ICD - 10 diagnosis
J - code
Its a type of injection , medication that he or she cannot injection administration, and for chemotherapy,
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
A health systems
How’s Novolin package?
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
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
And ICD-10 code
Example: ICD-10: E10.9 or E11.8
True out of pocket
TrOOP
Benefits, coordination and recovery center
BCRC
RDS
Retire, drug subsidy
What is 34B discount agreements call?
Pharmaceutical pricing agreement.
Manufacture agree to a pond discount on a drug so specified provider.
Specified provider are referred to as covered entity.
Lowest co-pay, usually generic drug, preferred
Tier 1
Higher copay, can be non-preferred generic, or preferred brand
Tier 2
Highest co-pay, usually drugs that are non-preferred brand or DAW brands with a generic 
 Tier 3
Speciallty drug that usually require a PA , could be a co-pay charge, or a percentage of the cost 
Tier 4
Information need to submit PA request:
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)
(Facility)Submitting a prior authorization
—medication PA requested typically begin at the pharmacy
— medical PA requested are handled with the billing office at a healthcare system
Process of submitting a prior authorization:
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.
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.
STEP THERAPY
Third-party prior authorization, rejection, troubleshooting, and resolution
Why/who can do the P)/ type of claims; who approves PA
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.
Common third-party prioritization Rejection troubleshooting , and resolution
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.
