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PT 101 Chapter 14

Key-Terms & Descirptions

Key-TermDescription
Third party programs Another party besides the patient or the pharmacy that pays for some or all of the cost medication: esentially, an insurer.
Pharmacy Benifit Manager (PBM) A company that administers drug benifit programs for insureance companies,HMOs, and self-insured employers.
Co-Insureance Essentially an agreement between the insured to share costs.
Co-Pay The portion of the cost of precriptions that patients with third party insurance must pay.
Deductible A set amount that must be paid by the patient for each benifit period before the insurer will cover additional expenses.
Usual and Customary (U&C) The MAC is often determined by survey of the usual and customary (U&C) prices for a prescription within a given goegraphic area. This is also referred to as the UCR (usual,customary,and reasonable) price for the prescription.
Prescription Drug Benifit Cards Cards that contain necessary billing information for pharmacies, including the patient's identification number,group number,and co-pay amount.
HMO (Health Maintenance organization) Health care networks that usually do not cover expenses incurred outside the network and often require genric substitution.
Point of service (POS) Health care network where the paitent's primary care physician must be a member and cost outside the network may be partially reimbursed.
Preferred provider organization (PPO) Health care network that reimburses expenses outside the network at a lower rate than inside the network and usually requires generic subsitution.
Workers' Compensation Compensation for employees accidentally injured on-the-job.
Medicare National health insureance for people over the age 65, dislabled people under age of 65,and people with kidneys failure.
Medicaid A fedreal-state program for the needy.
Online Adjudication Most prescription claims are now filed electronically by online claim submission and online adjudication of claims.In online adjudication,the techician uses the computer to determine the exact coverage for each prescription with the appropriate 3rd party.
Dispense As Written (DAW) When brand name drugs are dispensed,numbers corresponding to the reason for submitting the claim with brand name drugs are entered in a DAW (Dispense as written) indicator field in the prescription system.
Patient Identification Number The number assigned to the patient by that is indicated on the drug benefit card. If it does not match the code for the patient in the insurer's computer (with the same sex and other information) a claim may be rejected.
Age Limitations many prescription drug plans have age limitations for children or dependents of the cardholder.
Refills Most third party plans require that most of the medication has been taken before the plan will cover a refill of the same medication.
Maintenance Medications Many managed care health programs require mail oder pharmacies to fill prescriptions for maintenance medications.
Rejected Claims When a claim is rejected, the pharmacy technician can telephone the insurance plan's pharmacy help desk to determine if the patient is eligible for coverage.
Maximum allowable cost (MAC) The amount paid by the insurer is not equal to the retail price normally charged, but is determined by a formula described in a contract between the insurer and the pharmacy.
(MAC) There is a maximum allowable cost (MAC) per tablet or other dispensing unit that an insurer or PBM will pay for a given product.
Dual Co-Pay Co-pays that have two prices: one for generic and one for brand medications.
CMS 1500 (Formerly HCFA 1500 form) The standard form used by health care providers to bill for services.
CPT Code Identifiers used for billing pharmacist-provided MTMS.
Patient Assistant Programs Manufacturer sponsored prescription drug programs for the needy.
Universal Claim Form A standard claim form accepted by many insurers for billing drugs.
Formulary A list of medications covered by third party plans.
Tier Categories of medications that are covered by third party plans.
Medication Therapy Management Services (MTMS) Services provided to some medicare beneficiaries who are enrolled in Medicare Part D and who are taking multiple medications or have certain diseases.
Prescription Drug plans (PDPs) Third party programs for Medicare Part D.
National Provider Identifier (NPI) The code assigned to recongnized health care providers; needed to bill MTMS.
Current Procedural Terminology Codes (CPT Codes) Identifiers used for billing pharmacist-provided MTM Services.
CMS-10114 Form The standard form used by health care providers to apply for a National Provider Identifier (NPI). This six-page form,page one of which is known, is available by calling EPI Enumerator at 1-800-465-3203.
Created by: Bella_amg
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