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Pharmacy Billing and Reimbursement (Domain 8) > Pharmacy Billing and Reimbursement (Domain 8) > Flashcards

Pharmacy Billing and Reimbursement (Domain 8) Flashcards

1
Q

What is the meaning of the abbreviation “CMS”?

A

Center for Medicare and Medicaid Services

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2
Q

What is the meaning of the acronym “NPI”?

A

National Provider Identifier

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3
Q

What is the meaning of the acronym “HMO”?

A

Health Maintenance Organization

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4
Q

What is the meaning of the acronym “PPO”?

A

Preferred Provider Organization

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5
Q

What is the meaning of the acronym “POS”?

A

Point Of Sale

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6
Q

What is the meaning of the acronym “AWP”?

A

Average Wholesale Price

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7
Q

What is the meaning of the acronym “MAC”?

A

Maximum Allowable Cost (used for generic drugs)

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8
Q

What is the meaning of the acronym “DAW”?

A

Dispense As Written

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9
Q

What is the meaning of DAW 0?

A

physician authorized the dispensing of a generic drug

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10
Q

What is the meaning of DAW 1?

A

physician is requesting the brand name drug be dispensed

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11
Q

What is the meaning of DAW 2?

A

the physician authorized the dispensing of a generic drug; however the patient requested the brand name drug

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12
Q

Who determines the eligibility requirements for the federally funded Medicaid program?

A

State government

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13
Q

What is the meaning of HSA?

A

Health Savings Account

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14
Q

Which form of Medicare provides for prescription medications, biologicals, insulin, vaccines, and select medical supplies?

A

Medicare Part D

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15
Q

Which form of Medicare covers inpatient hospital care, skilled nursing facilities, hospice, and home care?

A

Medicare Part A

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16
Q

Which form of Medicare provides for physician services, outpatient care, and some physical and occupational therapy?

A

Medicare Part B

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17
Q

What is another name for Medicare Part C?

A

Medicare Advantage

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18
Q

What does Medicare Part C do?

A

It allows participants in Medicare Part A and B to obtain coverage through an HMO or PPO that provides additional services at a higher cost.

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19
Q

What did TRICARE replace?

A

CHAMPUS

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20
Q

Which organization replaced the HCFA (Health Care Financing Administration)?

A

CMS

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21
Q

Which agency is responsible for approving hospitals for Medicaid reimbursement?

A

HCFA (CMS)

22
Q

Which organization set regulations regarding the standards for resident care as a result of OBRA ‘87?

A

CMS

23
Q

What does a PBM do?

A

A Pharmacy Benefit Manager focuses on the pharmacy services provided under a health care plan. The PBM contracts with an insurer to provide prescription drugs to members usually through community pharmacies.

24
Q

Which organization developed the rejection codes for third-party prescriptions?

A

NCPDP

25
Q

What is the meaning of TJC?

A

The Joint Commission

26
Q

What does the acronym NCPDP stand for?

A

National Council for Prescription Drug Programs

27
Q

What is the largest single medical benefits program in the United States?

A

Medicare

28
Q

Which program provides coverage for military retirees and dependents of deceased military personnel?

A

CHAMPUS (TRICARE)

29
Q

Which program provides services to individuals older than 65 years of age, those who are blind, and those who are disabled from long-term disease?

A

Medicare

30
Q

Which federal program administered by the states is for individuals of lower income?

A

Medicaid

31
Q

What is Workers’ Compensation (Workers’ Comp)?

A

a federal program for workers who are injured on the job

32
Q

What is the meaning of AAC?

A

Actual Acquisition Cost

33
Q

What type of formulary is a limited list of drugs?

A

closed formulary

34
Q

What is an open formulary?

A

a formulary that allows for any medication to be dispensed

35
Q

What is a restricted formulary?

A

a hybrid of both an open and closed formulary system

36
Q

What term refers to a pharmacy receiving a predetermined amount of money for a patient regardless of the number of prescriptions filled or the value of the prescriptions each month?

A

capitation

37
Q

What term refers to the gap in Medicare coverage in which the patient is responsible for 100% of his or her prescription coverage?

A

“donut hole”

38
Q

What is another term for suggested retail price?

A

list price

39
Q

What is net profit?

A

Sales - COGS - Expenses

40
Q

What is the basic reimbursement formula for pharmacies?

A

drug cost + dispensing fee

41
Q

What term is defined by the cost of the coverage that the insurance policy contains, which may be affected by the age and health of the individual?

A

premium

42
Q

What term refers to the individual who receives the insurance policy or government health benefits?

A

beneficiary

43
Q

What term refers to the individual or organization protected under the terms of the condition (of an insurance policy)?

A

subscriber

44
Q

What is a third-party payer?

A

the fee for services provided by an insurance company

45
Q

What is the name of a company that administers drug benefit programs?

A

PBM (Pharmacy Benefit Manager)

46
Q

What does the abbreviation PBM stand for?

A

Pharmacy Benefit Manager

47
Q

What are 3 copayment arrangements used by third-party providers?

A

fixed copayment
percentage copayment
variable copayment

48
Q

What term refers to the amount of money a patient must pay in a given time period before the third-party insurer will make a payment?

A

deductible

49
Q

What is a copayment?

A

a predetermined amount of money or a percentage of money that one is responsible for paying on every prescription

50
Q

Which document do patients sign when they pick up a prescription covered by a third-party payer?

A

signature log

51
Q

What is the meaning of the acronym IPA?

A

Independent Practice Association

Pharmacy Billing and Reimbursement (Domain 8) (1 decks)

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