What Are Claims rejected Code

Question 1

01 code

Answer 1

Missing/invalid Bin

Question 2

09 code

Answer 2

Missing/invited birthdate

Question 3

11 code

Answer 3

Missing/invalid relationship code (00) himself, 02 (spouse,

Question 4

19 code

Answer 4

Missing/invalid days supply

Question 5

25 code

Answer 5

Missing/invalid prescriber ID – issue with prescriber NPI or DEA I is invalid

Question 6

66 code

Answer 6

Patient a exceed maximum age OK almost

Question 7

70 code

Answer 7

Product/service. Not covered. Drug is not cover on formulary.

Question 8

79 code

Answer 8

Review too soon

Question 9

Code 75

Answer 9

Prior authorization required – drug required prior authorization prior to dispense

Question 10

Pharmacy claims are considered to have a real time buildings where area medical claim do not it is a real time building that user show real pieces of information to process claim like patient information prescribe information, medication, date and place of service dosing, drug information and plan design

Answer 10

 Claim adjudication

Question 11

It’s a copay of coverage $5 or $10

Answer 11

Plan design

Question 12

Identified her that can be used by the insurance company to route pharmacy transaction by the processor to aid in receipt, and I justification of the claim

Answer 12

Processor control number (P CN)

Question 13

The database that tells your pharmacy which PBM should receive the claims

Answer 13

Bank identification number (BIN)

Question 14

Just is used to again to fly a drug and it has format 11 digits 542, versify identify the manufacture, Mito, four digits, identify medication, and the strength, the last two days to identify the package side and type of drug like capsule tablet

Answer 14

National drug coat (NDC)

Question 15

A 10 digit number that identifies a specific provider or entity Dash stays with that provider for life once assigned – not insurance specific.
Provider must use their NPI when transmitting any health electronic format
Key component in identifying fraud, like non-license, prescribers, sentient, prescriber, medical identity, theft and suspicious prescribing activities

Answer 15

National provider identifier (NPI)

Question 16

The price the business charges for a product

Answer 16

Selling price

Question 17

The amount a pharmacy pays for a drug

Answer 17

Cost or purchase price

Question 18

The amount added on top of pharmacy’s purchase price

Answer 18

Markup

Question 19

Markups formula

Answer 19

Markup = selling price - cost

Question 20

Markup percentage formula:

Answer 20

Markup % = ( markup/cost)x 100

markup = selling price - cost

Question 21

Net profit formula =

Answer 21

Net profit = income - overhead

Question 22

Average inventory formula =

Answer 22

Average inventory =
( initial inventor+ final inventor) /2
.

Question 23

Cost of goods sold The amount of the pharmacy pay for the goods sold to customer.
Includes the price the pharmacy pays for the product as well as shipping and other expense

Answer 23

Cost of goods sold

COGS

Question 24

Inventory, turnover rate formulary (ITOR) =

Answer 24

ITOR = COGS / average annual inventory

Remember: average annual inventory = (initial inv + fina inventory) / 2

Question 25

Five. Step of the lifecycle of a prescription claim.

Answer 25

One data entry end, the pharmacy staff member entered the prescription into the system.
-The prescription can be a electronically sent a brought in by the patient.
2-space claim is transmitted electronically.
- Pharmacy claims have real time billing
3-  claim is adjudicated.
- an accepting claim with a co-pay will generate or a rejected claim with information will generate
4- prescription is filled by license pharmacy stuff and checked by a licensed pharmacist for a safety and accuracy
5- the prescription is ready for pick up by patient and payment to be received at the time of pick up