Claims

Question 1

COB

Answer 1

Coordination of Benefits

When a pharmacy receives a prescription claim for a patient with multiple insurance plans, they must coordinate the benefits provided by each plan to ensure that the patient receives the maximum coverage available to them without exceeding the total cost of the medication. This involves determining which insurance plan is the primary payer and which is the secondary payer, as well as adhering to any specific rules or guidelines outlined by the insurance companies involved.

Question 2

MedRec

Answer 2

Medication Reconciliation

Medication reconciliation in pharmacy is a crucial process aimed at ensuring accuracy and safety in a patient’s medication regimen. It involves systematically reviewing the medications a patient is taking (including prescription drugs, over-the-counter medications, herbal supplements, and vitamins), comparing them to the medications prescribed during hospital admission, transfer, and discharge, and resolving any discrepancies or issues that arise.

Question 3

Adjudication

Answer 3

The process of determining whether a prescription drug claim is eligible for coverage under a patient’s insurance plan. It involves the electronic transmission of prescription information from the pharmacy to the insurance company or pharmacy benefit manager (PBM), where the claim is evaluated based on factors such as the patient’s coverage, copayment amount, formulary restrictions, and any other relevant criteria

Question 4

MPR

Answer 4

Medication Possession Ratio

This is a measure used to assess medication adherence. It calculates the proportion of time a patient has medication available to them compared to the total time they should have had the medication. It’s often used by healthcare providers and researchers to gauge how well patients are following their prescribed medication regimen. For
example, if a patient should have a 90-day supply of a medication and they only have it available for 60 days during that period, their MPR would be 0.67 (60/90).

Question 5

MAR

Answer 5

Medication Administration Record

The MAR is a legal document used by healthcare professionals, typically nurses, to track the administration of medications to patients. It serves as a record of what medications were administered, at what time, by whom, and via what route (such as orally, intravenously, or topically).
The MAR helps ensure patient safety and accuracy in medication administration by providing a clear record of each medication given to a patient during their hospital stay or other healthcare setting. It also serves as a communication tool among healthcare team members, allowing them to coordinate care and monitor the patient’s medication regimen effectively.
Each patient typically has their own MAR, which is updated regularly as medications are administered or changed. Healthcare professionals use the MAR to document medication administration promptly and accurately, following established protocols and guidelines to maintain patient safety and quality of care.

Question 6

Cycle Start Date

Answer 6

The beginning date of a patient’s medication cycle, particularly for medications that are dispensed in cycles, such as oral contraceptives or medications for chronic conditions.

Question 7

Analogues

Answer 7

Drugs or substances that are structurally or functionally similar to another drug or substance. These analogues may have similar pharmacological effects or properties, but they may also exhibit differences in potency, efficacy, or side effects. Analogues are commonly used in pharmacy for various purposes, including:

Question 8

M/I Service

Answer 8

Medication Information Service

This service is designed to provide patients with comprehensive information about their medications, including details about usage, potential side effects, interactions with other medications or substances, and any other relevant information.

Question 9

EDI

Answer 9

Electronic Data Interchange
A method used for the electronic exchange of prescription-related information, such as medication orders, prescriptions, refill requests, and other pharmacy-related transactions between healthcare providers, pharmacies, and payers: EDI streamlines the communication process, reducing the need for manual data entry and paper-based transactions, thus improving efficiency and accuracy in pharmacy operations. Additionally, EDI in pharmacy helps to ensure compliance with regulatory requirements and enhances patient safety by facilitating timely and secure transmission of prescription information.

Question 10

Third Party Claim Rejection

Answer 10

Instances where claims for medication reimbursement submitted by a pharmacy to a third-party payer (such as an insurance company or government health program) are rejected or denied.

Question 11

Third Party Payer

Answer 11

An entity other than the patient or the pharmacy that is responsible for reimbursing the cost of medications. These entities can include health insurance companies, pharmacy benefit managers (PBMs), Medicare, Medicaid, or other government health programs.

Question 12

Claims submission

Answer 12

When a patient purchases medication from a pharmacy and uses their
insurance coverage to pay for it, the pharmacy submits a claim to the third-party payer for reimbursement. This claim includes information such as the patient’s insurance information, details of the medication dispensed, and the cost.

Question 13

Rejections

Answer 13

When the third-party payer refuses to accept the claim submitted by the pharmacy. Rejections can happen for various reasons, including missing or incorrect information on the claim, eligibility issues with the patient’s insurance coverage, or discrepancies in the medication details.

Question 14

Denials

Answer 14

When the third-party payer initially accepts the claim but later decides
not to reimburse the pharmacy for the medication. Denials can occur due to reasons such as coverage limitations, prior authorization requirements not met, or the medication being deemed not medically necessary,

Question 15

Overrides

Answer 15

An authorization or approval granted by a pharmacist or other authorized personnel to bypass certain restrictions or limitations imposed by third-party payers.

Question 16

Authorization for Coverage (Override)

Answer 16

A medication may require prior authorization from the third-party payer before it can be covered if a claim is rejected due to lack of prior authorization. A pharmacist may need to initiate an override to indicate that the medication is medically necessary for the patient, thereby allowing the claim to be processed

Question 17

Formulary Restrictions (Override)

Answer 17

Many third-party payers maintain formularies, which are lists of preferred medications that are covered under their plans. If a medication prescribed by a physician is not on the formulary, the claim may be rejected. Pharmacists can use overrides to request coverage for non-formulary medications when they believe it is appropriate for the patient’s treatment.

Question 18

Quantity Limits (Override)

Answer 18

Some medications may have quantity limits imposed by third-party payers to
control costs or ensure appropriate use. If a claim is rejected due to exceeding the quantity limit, a pharmacist may need to override the restriction based on clinical judgment or patient-specific needs.

Question 19

Therapeutic Substitutions (Override)

Answer 19

Third-party payers may require pharmacists to substitute a
prescribed medication with a therapeutically equivalent alternative to lower costs. If a claim is rejected because the prescribed medication is not covered, pharmacists may use overrides to indicate that the prescribed medication is medically necessary or that the patient can not tolerate the alternative

Question 20

Billing Error (Override)

Answer 20

Overrides can also be used to correct billing errors or discrepancies identified during the claims submission process. For example, if a claim is rejected due to incorrect billing codes or missing information, a pharmacist may initiate an override to correct the errors and resubmit the claim for processing.

Question 21

340B

Answer 21

The 340B program, established in 1992 as part of the Public Health Service Act,
requires drug manufacturers to provide discounted outpatient drugs to eligible healthcare organizations known as “covered entities.” These covered entities typically include certain federally qualified health centers, disproportionate share hospitals, Ryan White HIV/AIDS Program grantees, and other safety-net providers. The purpose of the 340B program is to allow covered entities to stretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services. Covered entities can purchase discounted drugs through the 340B program and then dispense them to eligible patients. The savings generated from these discounted drug prices can be reinvested in patient care, such as providing additional services or medications to underserved
populations. In terms of pharmacy claims, the 340B program may impact billing and reimbursement processes. Pharmacies dispensing medications to patients eligible under the 340B program may need to follow specific guidelines and procedures to ensure compliance with program requirements. Additionally, there may be differences in reimbursement rates or billing procedures for medications purchased through the 340B program compared to those purchased through other means.

Question 22

Switch

Answer 22

Facilitates the electronic transmission of prescription information between the pharmacy’s system and external entities involved in the medication dispensing process, such as insurance companies and PBMs. This helps streamline the claims processing and medication fulfillment process, improving efficiency and accuracy for both the pharmacy and the patient.

Question 23

OCC

Answer 23

Other Coverage Code

A field used in pharmacy claims processing to indicate whether or not the patient has additional insurance coverage besides the primary insurance being billed for the prescription. When processing a pharmacy claim, the OCC field might contain codes or indicators that convey information about other insurance coverage the patient may have, such as Medicaid, Medicare, secondary insurance, or private insurance plans. This information is important for coordinating benefits between multiple insurers and ensuring accurate processing and reimbursement of pharmacy claims. By providing details about other insurance coverage, the OCC field helps prevent overpayments, ensures proper coordination of benefits, and assists in determining the patient’s financial responsibility for the prescription. Additionally, it helps pharmacies and insurers avoid duplicate payments or claims processing errors.

Question 24

DV (Override)

Answer 24

Days’ Supply Override (DV)

Situations where a pharmacist or pharmacy technician manually overrides the days’ supply of medication dispensed. For example, if a patient’s insurance plan limits them to a certain number of days’ supply per prescription, but the prescriber deems it medically necessary for the patient to have a different supply, the pharmacist may override the insurance restriction to provide the appropriate amount of medication.

Question 25

NP/NQ (Override)

Answer 25

Not Processed/Not Qualified

Indicates that a claim has not been
processed by the insurance provider or is not qualified for reimbursement. This could be due to various reasons such as incorrect patient information, missing or invalid prescription details expired insurance coverage, or other issues preventing the claim from being successfully processed.

Question 26

Primary Plan (Insurance)

Answer 26

The primary insurance plan is the first insurance coverage billed for prescription medications. This is typically the main insurance plan that the patient holds and is primarily responsible for covering their healthcare expenses. When a prescription is filled, the pharmacy will first submit a claim to the primary insurance plan for processing and reimbursement.

Question 27

Secondary Plan (Insurance)

Answer 27

The secondary insurance plan is the additional insurance coverage that may
exist beyond the primary plan. If the primary insurance plan does not cover the entire cost of the prescription or if there are remaining copayments or deductibles after the primary insurance pays its portion, the pharmacy may then submit a claim to the secondary insurance plan. The secondary plan may provide additional coverage to help cover the remaining costs or may contribute towards copayments or deductibles.

Question 28

Copay

Answer 28

A copayment is a fixed amount that a patient pays out-of-pocket for a covered healthcare service or medication, typically at the time the service is rendered or the prescription is filled. Copayments are predetermined fees set by the insurance plan and are usually specified in the patient’s insurance policy. They can vary depending on the type of service or medication received. Copayments are intended to share the cost of healthcare between the patient and the insurance provider, with the patient responsible for paying the specified copayment amount, and the insurance provider covering the remainder of the cost.

Question 29

Deductible

Answer 29

A deductible is the amount of money that a patient must pay out-of-pocket for covered healthcare services or prescriptions before their insurance plan begins to cover costs. Once the deductible is met, the insurance plan typically begins to cover a portion or all of the costs, depending on the plan’s terms and conditions Deductibles can vary widely depending on the insurance plan and may apply to different types of services or medications. For example, a health insurance plan may have separate deductibles for medical services and prescription drugs. Deductibles can reset annually, meaning that the patient may need to meet the deductible again at the beginning of each new coverage period (e.g., calendar year or plan year).

Question 30

Coupon (Secondary Plan)

Answer 30

When the secondary insurance plan is referred to as a “coupon,” it typically means that the secondary coverage is not traditional insurance but rather a discount program or manufacturer coupon offered by a pharmaceutical company. These coupons are often provided directly by drug manufacturers as a way to reduce out-of-pocket costs for patients when purchasing specific medications. They may be used to lower
copayments or reduce the cost of the medication itself. Coupon programs often have eligibility criteria and restrictions set by the manufacturer, and
they may only apply to certain medications or be subject to specific terms and conditions.

Question 31

Commercial (Secondary Plan)

Answer 31

When the secondary insurance plan is described as “commercial,” it means that the secondary coverage is provided by a traditional commercial health insurance plan. Commercial insurance plans are those offered by private insurance companies, employers, or healthcare exchanges and are typically purchased by individuals or provided as part of an
employment benefit. Commercial insurance plans may have various levels of coverage, copayments, deductibles,
and networks of healthcare providers and pharmacies, depending on the specific plan chosen by the individual or employer.

Question 32

SureScript

Answer 32

A health information network in the United States that facilitates the electronic exchange of prescription information between healthcare providers, pharmacies, pharmacy benefit managers (PBMs), and other entities involved in the medication prescribing and dispensing process.

Question 33

Remit (EOB)

Answer 33

Explanation of Benefits or
remittance advice provided by a third-party payer (such as an insurance company or pharmacy benefit manager) to the pharmacy after a claim has been processed. The remittance advice contains detailed information about how the claim was processed, including:
1. Payment Details: It specifies the amount paid by the payer for the claim, including any copayments, deductibles, or coinsurance amounts covered by the patient, as well as the amount reimbursed to the pharmacy.
2. Reason Codes: The remittance advice often includes reason codes or explanation codes that provide information about why a claim was paid, adjusted, or denied. These codes help the pharmacy understand the rationale behind the payment decision and address any issues with the
claim submission if necessary.
3. Patient Responsibility: It indicates any remaining balance that the patient is responsible for paying, such as copayments or coinsurance amounts not covered by the insurance plan.
4. Claim Status: The remittance advice may also include information about the status of the claim, such as whether it was paid in full, partially paid, or denied.
5. Additional Information: Depending on the payer, the remittance advice may contain additional details or instructions for the pharmacy, such as information about prior authorization requirements, preferred drug lists, or other formulary considerations.

Question 34

BIN # (Insurance)

Answer 34

Bank Identification Number

BIN is a unique identifier assigned to a pharmacy by the electronic data interchange (EDI) processor or third-party payer. It identifies the pharmacy’s financial institution or processor. When a pharmacy submits a prescription claim electronically, the BIN is included in the transaction to specify which payer network the claim should be routed to for processing. The BIN is typically the first set of numbers in the pharmacy’s electronic billing information.

Question 35

PCN # (Insurance)

Answer 35

Processor Control Number

PCN is a secondary identifier used in pharmacy claims processing to further specify the payer or plan within a specific BIN. While the BIN identifies the overall network or processor, the PCN provides additional information about the specific plan or program within that network.
The PCN helps ensure that the claim is routed to the correct plan within the larger network, especially in cases where multiple plans are managed by the same processor. The PCN is typically provided by the insurance company or PBM and is specific to each plan or group of plans within their network.

Question 36

Prior Authorization

Answer 36

A prior authorization (PA) is a process used by insurance companies or pharmacy benefit managers (PBMs) to determine coverage for certain medications that may require additional scrutiny before being approved for reimbursement.

Question 37

Medicaid

Answer 37

Medicaid is a joint federal and state program that provides health coverage to low-income individuals and families, including children, pregnant women, elderly adults, and people with
disabilities. Eligibility for Medicaid is based on income and other factors, and coverage varies by state. Medicaid covers a wide range of medical services, including doctor visits, hospital stays,
prescription drugs, and preventive care.
Medicaid also offers coverage for long-term care services and supports for individuals who meet certain eligibility criteria.

Question 38

Medicare Part D

Answer 38

Medicare Part D is a federal program that provides prescription drug coverage to Medicare beneficiaries. It is offered through private insurance plans approved by Medicare. Medicare Part D coverage is optional and available to individuals enrolled in Medicare Part A
(hospital insurance) or Part B (medical insurance). Beneficiaries can enroll in a standalone Part D prescription drug plan or choose a Medicare Advantage plan that includes prescription drug coverage.
Medicare Part D plans vary in terms of premiums, deductibles, copayments, and covered medications. Beneficiaries can choose a plan that best meets their prescription drug needs and budget.

Question 39

A/R Account

Answer 39

Accounts Receivable

A financial term that represents the money owed to a pharmacy for goods or services provided to customers or patients on credit

Question 40

Categories (Patient Profile)

Answer 40

A classification or grouping of patients based on certain criteria. This categorization allows pharmacy staff to organize patient profiles and manage them more efficiently. Here’s how the
category section may be used:
1. Medication Therapy Management (MTM) Categories: Pharmacies may categorize patients based on eligibility for medication therapy management (MTM) services. MTM categories may
include patients with chronic conditions, high-risk medications, or complex medication regimens who would benefit from additional pharmacist intervention and counseling.
2. Insurance Plan Categories: Patients may be categorized based on their insurance plans or coverage types. This helps pharmacy staff identify patients with specific insurance requirements
or restrictions and ensures that claims are processed correctly based on each patient’s insurance
coverage.
3. Medication Synchronization Categories: Pharmacies that offer medication synchronization
services may categorize patients based on their enrollment status in the synchronization program. This allows pharmacy staff to coordinate prescription refills and medication pickup schedules for patients enrolled in the program.
4. Specialty Medication Categories: Patients prescribed specialty medications may be categorized
separately to ensure specialized handling, monitoring, and coordination of their medication therapy.
5. Clinical Criteria Categories: Patients may be categorized based on clinical criteria such as disease state, medication allergies, or medication interactions. This helps pharmacy staff identify patients who require special attention or additional clinical support.
6. Billing Categories: Patients may be categorized based on billing preferences or payment methods. For example, patients who participate in medication adherence programs or discount
programs may be categorized accordingly to ensure accurate billing and reimbursement.