Vocabulary Ch. 14 Flashcards
The standard six-page form used by health care providers to apply for a national provider identifier (NPI)
CMS-10114 form
An agreement for cost-sharing between the insurer and the insured
Co-insurance
The portion of the price of medication that the patient is required to pay
Co-pay
Identifiers used for billing pharmacist-provided MTM services
Current Procedural Terminology codes (CPT codes)
A set amount that must be paid by the the patient for each benefit period before the insurer will cover additional expenses
Deductible
Co-pays that have two prices: one for generic and one for brand medications
Dual Co-pays
A list of medications covered by third-party plans
Formulary
A network of providers for which costs are covered inside but not outside of the network
HMO
The maximum price per tablet an insurer or PBM will pay for a given product
Maximum Allowable Cost (MAC)
A federal-state program, administered by the states, providing health care for the needy
Medicaid
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
Medicare
Services provided to some Medicare beneficiaries who are enrolled in Medicare Part D and who are taking multiple medications or have certain diseases
Medication Therapy Management (MTM) services
The code assigned to recognize health-care providers; needed to bill MTM services
National Provider Identifier (NPI)
The resolution of prescription coverage through the communication of the pharmacy computer with the third-party computer
Online adjudication
The standard form used by health-care providers to bill for services, including disease state management services
CMS-1500 form
Manufacturer sponsored prescription drug programs for the needy
Patient assistance programs
Companies that administer drug benefit programs
Pharmacy benefit managers
A network of providers where the patient’s primary care physician must be a member and costs outside the network may be partially reimbursed
POS
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
PPO
Cards that contain third-party billing information for prescription drug purchases
Prescription drug benefit cards
Third-party programs for Medicare Part D
Prescription Drug Plan (PDP)
Categories of medications that are covered by third-party plans
Tier
The maximum amount of payment for a given prescription, determined by the insurer to be a usual and customary and reasonable price
U&C or UCR
A standard claim form accepted by many insurers
Universal claim form (UCF)
An employer compensation program for employees accidentally injured on the job
Worker’s compensation
