Vocabulary Ch. 14

Question 1

The standard six-page form used by health care providers to apply for a national provider identifier (NPI)

Answer 1

CMS-10114 form

Question 2

An agreement for cost-sharing between the insurer and the insured

Answer 2

Co-insurance

Question 3

The portion of the price of medication that the patient is required to pay

Answer 3

Co-pay

Question 4

Identifiers used for billing pharmacist-provided MTM services

Answer 4

Current Procedural Terminology codes (CPT codes)

Question 5

A set amount that must be paid by the the patient for each benefit period before the insurer will cover additional expenses

Answer 5

Deductible

Question 6

Co-pays that have two prices: one for generic and one for brand medications

Answer 6

Dual Co-pays

Question 7

A list of medications covered by third-party plans

Answer 7

Formulary

Question 8

A network of providers for which costs are covered inside but not outside of the network

Answer 8

HMO

Question 9

The maximum price per tablet an insurer or PBM will pay for a given product

Answer 9

Maximum Allowable Cost (MAC)

Question 10

A federal-state program, administered by the states, providing health care for the needy

Answer 10

Medicaid

Question 11

A federal program providing health care to people with certain disabilities or who are over the age of 65; it includes basic hospital insurance, voluntary medical insurance, and voluntary prescription drug insurance

Answer 11

Medicare

Question 12

Services provided to some Medicare beneficiaries who are enrolled in Medicare Part D and who are taking multiple medications or have certain diseases

Answer 12

Medication Therapy Management (MTM) services

Question 13

The code assigned to recognize health-care providers; needed to bill MTM services

Answer 13

National Provider Identifier (NPI)

Question 14

The resolution of prescription coverage through the communication of the pharmacy computer with the third-party computer

Answer 14

Online adjudication

Question 15

The standard form used by health-care providers to bill for services, including disease state management services

Answer 15

CMS-1500 form

Question 16

Manufacturer sponsored prescription drug programs for the needy

Answer 16

Patient assistance programs

Question 17

Companies that administer drug benefit programs

Answer 17

Pharmacy benefit managers

Question 18

A network of providers where the patient’s primary care physician must be a member and costs outside the network may be partially reimbursed

Answer 18

POS

Question 19

A network of providers where costs outside the network may be partially reimbursed and the patient’s primary care physician need not be a member

Answer 19

PPO

Question 20

Cards that contain third-party billing information for prescription drug purchases

Answer 20

Prescription drug benefit cards

Question 21

Third-party programs for Medicare Part D

Answer 21

Prescription Drug Plan (PDP)

Question 22

Categories of medications that are covered by third-party plans

Answer 22

Tier

Question 23

The maximum amount of payment for a given prescription, determined by the insurer to be a usual and customary and reasonable price

Answer 23

U&C or UCR

Question 24

A standard claim form accepted by many insurers

Answer 24

Universal claim form (UCF)

Question 25

An employer compensation program for employees accidentally injured on the job

Answer 25

Worker’s compensation