Midule 1 (Billing & Reinbursement Of The 3rd Party

Question 1

Lead transformation in the pharmacy services factor by creating and promoting standard for electric healthcare transaction. It’s promote industry solution that improve patient,,safety health outcomes and reduce cost.
It’s go to make sure outcome a positive.
A real time claim adjuster , eligibility, and benefit verification, real time, ordering by the physician, and sharing of the medication history.

Answer 1

National Council for prescription drug programs (NCPDP)

Question 2

-Choose a primary care physician, and all of your healthcare services go through that physician
-2 things set HMOs apart from other types of healthcare plans cost and choice
Typically has lLOWER monthly premiums with lower co-pay and cones shooting with no out of network coverage
except in the case of true emergency.
- Has their own network of doctors, hospital, and other healthcare provider who has agreed to accept payment at a certain level for any service they provide.

Answer 2

Health maintenance organization (HMO)

Question 3

-More flexibility offered in selecting a doctor or hospital and sometimes cover the cost and visits to out of network provider.
You do not need a primary care physician and I able to go to any healthcare professional new one without a referral
-

Answer 3

Preferred provider organization (PPO)

Question 4

What is a center of Medicare and Medicaid services (CMS)

Answer 4

You provide health coverage through Medicare, Medicaid, the children, health insurance program (CHIP)
provide access to high quality care and improved health care at no cost.
CMS is a part of department of health and human services. .(HHS)

Question 5

Lead transformation in the pharmacy, so this is sector by creating and promoting standards for electronic health care transaction
Real time claim adjudication, eligibility, and benefits of dedication, real time, ordering by the physician.
It make sure outcome positive and enter make sure the outcomes are positive. Whenever the transfer of this information happens electronically every keeping in mind that pharmacy is real time it happeneda second u turn the switch real time and

Answer 5

National Council for prescription drug program (NCPDP)

Question 6

Medical —part A ( hospital insurance)

Answer 6

Help cover, inpatient care in hospital, critical access, hospitals, skilled nursing facility ( not custodial or long-term care), hospice care, and some healthcare if .certain conditions are met.
— if you are spouse, do not pay Medicare taxes while you work and you are a 65 and older and a citizen or permanent resident of United States you might be able to buy part A
If you do not qualify for premium free Part. A , a standup premium is $458 each month if you pay Medicare taxes for less than 30 quarter but if you pay Medicare taxes for 30 to 39 quarters the stand up with them is $ 252 each month.

Question 7

Medical —Part B (Medical Insurance)
Example of coverage.
Clinical research, ambulance, service, durable, medical equipment, mental health (inpatient, outpatient, partial hospitalization), Limited outpatient prescription, drugs.

— Covers two types of service:
— 1. medical necessity preventive services
—2 . Preventive services

Answer 7

Medicare part B

Question 8

Medical Part B:

Coverage is based on 3 factors:

Answer 8

Federal and state laws, national coverage decisions, made by Medicare about whether something is covered in local coverage decisions made by a company in each state that process claim for Medicare

—Premium amount is $144.60 each month

Question 9

Accept healthcare reimbursement type in different setting:
Home health care
Long-term care
Home infusion
Health systems
Community pharmacy
Ambulatory clinic

Answer 9

Home health : medicare, Medicaid, VA, private health, insurance and out-of-pocket.
Long-term care.: medicare, Medicaid and private insurance (all have separate requirements)
Home infusion: medicare, Medicaid, and private insurance, TRICARE, self-pay.
Health system: medicare, Medicaid, private, insurance, charity programs, self-pay, TRICARE
Community : private insurance, Medicare, Medicaid, TRICARE, self-pay.
Ambulatory clinic.: medicare, Medicaid, private insurance, tricare , charity program, self pay.

Question 10

Third-party reimbursement types. What is PBM?

Answer 10

PBM is pharmacy benefit manager
Administers prescription, drug plans, from a variety of sponsors, including commercial health, plans, self insured employer plans, union plans, medical part, D plans, the federal employees health benefit program (FEHBP), state government employee plans, managed Medicaid plans.
Example include optum Rx, or caremak, express, scripts, smaller boutique, PBM.

Question 11

Aligibility for patient assistance through available programs : what is medication assistant program?

Answer 11

Is offered by the drug manufacturing company or local or state level programs to patient with no or limited pharmacy benefit coverage to help with medication cost.
-Typically has income limits for eligibility that are based on the national poverty level

Question 12

Medicare part D (prescription drug)

Answer 12

Yearly deductible.
— no Medicare drug plan maybe have a deductible more than $435 in 2020. Some plans have no deductible.
Coverage gap.— the “donut hole”
— a temporary limit on what the drug plan will cover for drugs
— not everyone will enter the gap; the coverage gap begins after you and your drug plan have spent a certain amount for covert drugs
— $4020 on cover drug in 2020
— once in the gap, you will pay no more than 25% of the total cost for your plans covered brand prescription drugs, however, 95% of the cost of the drug will count toward your out-of-pocket spend it.
— once you have spent $6350 out of pocket in 2020, you are out of the coverage gap and you will automatically get “catastrophic coverage “which assures which assure you only pay a small coinsurance amount or co-pay for drugs for the remainder of the year..

Question 13

Self pay

Answer 13

Uninsured, cash pay
Paying out-of-pocket with no insurance
Due to being unsure or better cash pricing
Prescription discount cards are typically used by someone who is self-pay

Question 14

Eligibility for patient assistant, through available programs 340 B

Answer 14

-Enable covered entities to stretch scarce federal resources as far as possible while manufactured participating with Medicaid agree to provide outpatient drugs to cover entities at a significant reduced price.
-eligible healthcare organizations/covered entities are defined in statute and include HRSA (human resource service).HRSA supported “health center and look like Ryan White clinic and state AIDs drug assistant programs , Medicare/Medicaid Disproportionate share hospital, children’s hospital, and all those safety net providers
-A covered entity must keep 340B OPAIS information, accurate, and up-to-date, recertify a little ability every year, prevent this devotion, to ineligible patients, duplicate discount, prohibit,, and prepare for a program audits
-A patient is eligible for 340B drugs if they receive healthcare service from 340B to be covered entity

Question 15

Eligibility for patient assistance through available programs

Answer 15

Medication assistant program (drug manufacturers shipped directly to your home
- offer by the drug manufacturing company or local or state level programs to patience with no are limited pharmacy benefit coverage to help with medication cost.
- typically has income limits for eligibility that are based on national property level.
(Free medication for manufacture, with strict guidelines provide proof of income W-2 for uninsured, no insure and ,below national property.

Question 16

Medical —Part C (Medicare Advantage)

Answer 16

—all in one alternative to original Medicare (AB, and usually D)— original Medicare exist, even if you buy up.
—The buy up for part C depends on several different factor and it is very similar to regular private insurance option.
—offered by private companies approved by Medicare.
—Plans may have lower out of pocket cost and original Medicare.
—Typically will need to use Dr. was in the plans network typically have access to additional benefit that original Medicare does not cover such as vision, hearing, and dental.