Pharmacy Billing and Reimbursement (Domain 8)

Question 1

What is the meaning of the abbreviation “CMS”?

Answer 1

Center for Medicare and Medicaid Services

Question 2

What is the meaning of the acronym “NPI”?

Answer 2

National Provider Identifier

Question 3

What is the meaning of the acronym “HMO”?

Answer 3

Health Maintenance Organization

Question 4

What is the meaning of the acronym “PPO”?

Answer 4

Preferred Provider Organization

Question 5

What is the meaning of the acronym “POS”?

Answer 5

Point Of Sale

Question 6

What is the meaning of the acronym “AWP”?

Answer 6

Average Wholesale Price

Question 7

What is the meaning of the acronym “MAC”?

Answer 7

Maximum Allowable Cost (used for generic drugs)

Question 8

What is the meaning of the acronym “DAW”?

Answer 8

Dispense As Written

Question 9

What is the meaning of DAW 0?

Answer 9

physician authorized the dispensing of a generic drug

Question 10

What is the meaning of DAW 1?

Answer 10

physician is requesting the brand name drug be dispensed

Question 11

What is the meaning of DAW 2?

Answer 11

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

Question 12

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

Answer 12

State government

Question 13

What is the meaning of HSA?

Answer 13

Health Savings Account

Question 14

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

Answer 14

Medicare Part D

Question 15

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

Answer 15

Medicare Part A

Question 16

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

Answer 16

Medicare Part B

Question 17

What is another name for Medicare Part C?

Answer 17

Medicare Advantage

Question 18

What does Medicare Part C do?

Answer 18

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.

Question 19

What did TRICARE replace?

Answer 19

CHAMPUS

Question 20

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

Answer 20

CMS

Question 21

Which agency is responsible for approving hospitals for Medicaid reimbursement?

Answer 21

HCFA (CMS)

Question 22

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

Answer 22

CMS

Question 23

What does a PBM do?

Answer 23

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.

Question 24

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

Answer 24

NCPDP

Question 25

What is the meaning of TJC?

Answer 25

The Joint Commission

Question 26

What does the acronym NCPDP stand for?

Answer 26

National Council for Prescription Drug Programs

Question 27

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

Answer 27

Medicare

Question 28

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

Answer 28

CHAMPUS (TRICARE)

Question 29

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?

Answer 29

Medicare

Question 30

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

Answer 30

Medicaid

Question 31

What is Workers' Compensation (Workers' Comp)?

Answer 31

a federal program for workers who are injured on the job

Question 32

What is the meaning of AAC?

Answer 32

Actual Acquisition Cost

Question 33

What type of formulary is a limited list of drugs?

Answer 33

closed formulary

Question 34

What is an open formulary?

Answer 34

a formulary that allows for any medication to be dispensed

Question 35

What is a restricted formulary?

Answer 35

a hybrid of both an open and closed formulary system

Question 36

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?

Answer 36

capitation

Question 37

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

Answer 37

"donut hole"

Question 38

What is another term for suggested retail price?

Answer 38

list price

Question 39

What is net profit?

Answer 39

Sales - COGS - Expenses

Question 40

What is the basic reimbursement formula for pharmacies?

Answer 40

drug cost + dispensing fee

Question 41

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?

Answer 41

premium

Question 42

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

Answer 42

beneficiary

Question 43

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

Answer 43

subscriber

Question 44

What is a third-party payer?

Answer 44

the fee for services provided by an insurance company

Question 45

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

Answer 45

PBM (Pharmacy Benefit Manager)

Question 46

What does the abbreviation PBM stand for?

Answer 46

Pharmacy Benefit Manager

Question 47

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

Answer 47

fixed copayment percentage copayment variable copayment

Question 48

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?

Answer 48

deductible

Question 49

What is a copayment?

Answer 49

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

Question 50

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

Answer 50

signature log

Question 51

What is the meaning of the acronym IPA?

Answer 51

Independent Practice Association