Pharmacy Business Module 4 Flashcards
Systematic reviews and evaluations of records and other data to determine quality of services or products provided.
audits
A person designated by an insurance policy to receive benefits or funds.
beneficiary
A comprehensive health care program in which the Office of Veterans’ Affairs (VA) shares the cost of covered health care services and supplies with eligible beneficiaries.
CHAMPVA
An arrangement in which the insured must pay either a fixed amount or a percentage of the cost of medical services covered by the insurer.
coinsurance
A legally enforceable agreement.
contract
A process in which two or more insurance companies apportion each one’s share of responsibility of payment of a claim for health care services provided to an insured client.
coordination of benefits
A cost-sharing requirement of most insurance policies, under which it is the responsibility of the insured to make a payment of a specified amount (e.g., $20) at the time of treatment or purchase of a prescription. Some policies have both a copayment and coinsurance clause.
copayment
A rejection of a medication refill due to an amount that has exceeded the preapproved supply for a specific period of days.
days supply exceeded
A specific amount of money that must be paid yearly before the policy benefits begin (e.g., $50, $100, $300, or $500). The higher the deductible, the lower the cost of the policy; and the lower the deductible, the higher the cost of the policy
deductible
The spouse and children of the insured who are also covered under the terms of the policy.
dependents
An evaluation of a pharmacy or related facility that does not involve an auditor being sent out to the location; it is less intensive than a field audit.
desk audits
A type of contract purchased by individuals or employers that provides reimbursement for specified medical and related expenses.
health insurance
The determination of the exact coverage to which the insured is entitled. The pharmacy technician may be responsible for checking on a customer’s or patient’s eligibility of coverage. This can be done over the telephone, via a voice-automated system, using computer software, over the Internet, or by checking an eligibility list for a managed care plan
eligibility
An intensive, systematic investigation of a pharmacy or other facility’s operational practices, procedures, records, inventory, and accounting.
field audits
A government-funded program that pays for health coverage for people over age 65, and certain other persons.
Medicare
A government-funded health cost assistance program that pays for health services and pharmacy expenses for enrolled U.S. citizens who cannot afford to pay for their own health care. It also covers those who are blind, disabled, orphaned, or underage parents.
Medicaid
A type of health plan providing coverage within Part C of Medicare; it pays for managed health care based on a monthly fee rather than on the basis of billing a fee for each service provided.
Medicare Advantage plan
Payment by the insurer or by the patient of more than the amount due.
overpayment
An individual numeric code that identifies a specific patient, used in pharmacies and other health care facilities.
patient identification number
Prior authorization; many private insurance companies and prepaid health plans have certain requirements that must be met before they will approve diagnostic testing, hospital admissions, inpatient or outpatient surgical procedures, other specific procedures, and specific treatment or medications. For example, most outpatient intravenous therapies require a prior approval authorization.
preauthorization
A rejection of a medication refill in which the amount requested exceeds the amount allowed by insurance plan.
plan limitations exceeded
The exclusion of specific medical conditions or procedures from reimbursement under a health insurance policy. Some types of exclusions are acquired immunodeficiency syndrome (AIDS), attempted suicide, cancer, losses due to injury on the job, and pregnancy.
policy limitation
The individual or organization protected in case of loss under the terms of an insurance policy. The subscriber is known as an insured, member, policyholder, or recipient. In group insurance, the employer is known as the insured and the employees are the risks.
subscriber
The cost of the coverage provided by an insurance policy; this may vary greatly depending on the age and health of the individual and the type of insurance protection. The premium may be paid in full or in part by the employer and/or the employee.
premium
A rejection of a medication refill in which the refill has been requested too soon after a previous refill was requested.
refill too soon
An organization or corporation that pays medical claims for patients; third-party payers reimburse providers directly, with patients making only any required copayments.
third-party payer
The period of time that an individual must wait to become eligible for insurance coverage (e.g., 30 days), before coverage commences or for a specific benefit (e.g., an employee must wait 9 months before seeking maternity benefits); also known as an elimination period.
waiting period
A health care program serving active duty service members, members of the National Guard (including reserve members), retirees, their families, survivors, and selected former spouses worldwide.
TRICARE
