Module 4 ( Billing & Reimbursement Of 3rd Party) Flashcards
Generally referred to as Obama care – it is the landmark health reform registration passed by the 111th Congress and signed into law by President Barack Obama in March 2010
 Affordable Care Act (ACA)
It is a benchmark that has been used over 40 years  for pricing and reimbursement a prescription drug for both government and private payers. He has often been compared to the ‘ list price ‘ or ‘ stickerprice ’Meaning it is an elevated drug price that is really what it is actually paid.
 Average wholesale price (AWP)
The batch and claims give father information about a claim then what it is seeing on the initial screen
Batch/claim (BNC)
Insure an agency this is the person that help you to find your insurance. They are the ones that are negotiating the best price/coverage for you or your company.
 Broker
Define narrowly refers to the third tier health insurance plan that allows member to the health saving account (HSA), or
Health Reinbursement Account (HRA)or similar medical, payment,product to pay routing healthcare expensive directly .
Consumer Driven Health plan CDC)
Code that are an integral part of a accurate, billing, and provide us with the reason why a specific brand or generic, is dispense based on the prescriber instruction.
Dispense As Written (DAW)
Employee benefits include various types of non-wage compensation, provided to employees in addition to their normal wages or salaries
Employer Benefits (EEB)
No one person meet more than the individual maximum amount. Once they have met it, they move on to the next tier in the process (co-pay or no co-pay); it is then up to the rest of the member (all of the co-pay added together) to meet the family maximum amount, it means everything get it together
Embedded
a saving account used in conjunction with a high deductible, health insurance policy that allows users to save money, tax free against medical expenses
Health Saving Account (HSA)
A plan with a higher deductible than a traditional insurance plan. The IRS defines a high deductible health plan, as any plan with a deductible of at least $1,350 for an individual or $2700 for a family
High Deductible Health Plan (HDHP)
A healthcare common procedure coding system (HCPCS) level II alpha - numberic code issued by CMS to identify and describe a drug product. And describe a procedure that was happened. alpha numeric code. It was issued by the CMS and get paid for that, but that J- code needs to be written on that prescription so that way when it is audited, we could see it exactly what it is very important to the diagnosis that we are treating with a specific drug product.want to know exactly FDA approval and do u needed h this expensive? Drug product specific and specific diagnosis, exactly reason why do u need for aFDA or really needed,,
Medical Exclusion (J-Code)
When a doctor requires a member to have a brand-name prescription that has a generic available in the market place, and letter of medical necessity should be attached with the PA.
Letter of Medical Necessity (LOMN)
Generally refers to a payer or PBM generated list of products. That includes the upper limit or maximum amount that a plan will pay for generic drugs or brand-name.
Maximum Allowable Cost (MAC)
The PBM practice of negotiating, a lower cost with the pharmacy and building a higher cost to the patient. The PBM keeps the difference or ‘ spread.’
Mac Spread
The whole family deductible/OOP must be met before anyone can move to the next step. No one is left behind. They all move together or no one moves. Even if one member meets , the individual amount, they will not move until the family amount is Met. There’s only apply to the non-embedded plants that have one or more members.
Non-Embedded
A national provider, identifier or It is a unique 10 digits identify the number is used to healthcare providers
National provider identifier (NPI)
The most you have to pay for cover service in a plan yet. After you spend this amount or deductible, co- payment, and coinsurance, your health plan pay 100% of the cost of covered benefit.
Out-of-pocket
Medication that I sold over the counter without a prescription
Over the counter (OTC)
This is a process of obtaining physician authorization prior to the member receiving service. The purpose of the prior-authorization function is for physicians to determine member eligibility, benefits,coverage , medical necessity , location, and appropriateness of services
Prior Authorization. (PA)
It is a programs created by a pharmaceutical and medical supply manufacturers to help financially needed patient purchase necessary medication and supplies.
Patient Assistance Program (PAP)
In the United States, and pharmacy benefit manager is a third-party administration of a prescription program.
Pharmacy benefits, manager. (PBM)
Per employee per month refer to the average cost of service to an employee for a one -month.- period. It may also include cost for a spouse, partner, and/or dependent if they are covered under the employee sponsor health plan
Per Employee Per Mont (PEPM)
The standard form used by healthcare provider to bill for services, including disease state management services, people don’t do electronically billing
CMS-1500 Form
The standard claim form accepts by many ensured it is a documentation and a form
Universal Claim Form . (UCF)
Federal laws and regulations
HIPPA and national regulation.
HIPAA the health insurance portability and accountability act.
Patient confidentiality
HIPAA 5010 is a requirement for all electronic patient data to be confidential, according to the HIPAA standards their data themselves.
Use of ICD - 10 codes which allow for more specificity in the reporting of patient diagnosis.all your medical code diagnosis what exactly something wrong with u and j -code down to the drugs and then you got the ICD 10 that runs on what the diagnosis is so a lot of times you got the ICD-10 code in work very hand-in-hand in pharmacy J Code rent all of your drugs together.
Accrediting, Bodies and Surveys : u follow this standard
Center of Medicare and Medicaid Services. (CMS): this is the standard and rule u need to follow
Uilization Review Accreditation Commission. (URAC) -volunteer, best out come , it gives
The joint commission (TJC) -nonprofit, volunteering, lo
Patient satisfaction survey.
DNV— it is the organization purpose is to safeguard life, property, and environment to ghost is to compliance and educate hospital in best practice. Is it a requirement for accreditation through the NBA as directly related to CMS condition of participant (cop’s)
the requirement for accreditation through DNV are directly related to CMS condition of participation (CO PS) they apply to any state hospital, and they less prescriptive than any other credediting agencies’ stander— giving healthcare organization, debility to powder, eyes initiative for continuously, improvement: at three categories: accredited ( meet corrective action, plan, requirements, ), jeopardy status(fail to meet, corrective action, plan requirements) , not accredited
Agency with the department of health and human services responsible for providing health service Jameka Indian, an Alaskan native
Indian health services
Someone who receive health insurance from a federal program, a program paid by the government example Medicare Medicaid TRICARE, veteran affair, Indian health
What is a federal beneficiary?
What is commercial insurance?
-its known as ‘private insurance this is health insurance pay for privately as an individual.
-employment
- Market Place.
-Coverage varies widely, and there are many choices
Which program is jointly funded by both federal government and and state?
Medicaid
