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Ch.6 Insurance

Claim Preparation and Transmission

QuestionAnswer
Most claims are filed this way Electronically
The beginning point for filing a claim. This information is vital to a successful claim submission. Recording correct patient information
The prescriber ID number may comprise these two different identifiers NPI number and DEA number
A dependent child's insurance coverage that is determined by the parent whose date of birth is earlier in the calendar year is known as this Birthday Rule
A set of NCPDP codes used to inform third parties of the reason why a brand or generic product was used to fill a prescription Dispense As Written (DAW) codes
The greatest unit price that a payer or PBM will pay MAC (maximum allowable cost)
This enables providers to submit electronic pharmacy claims in an online real-time environment Real-time claims management systems
The HIPAA standard for electronic retail pharmacy drug claims NCPDP Telecommunications Standard Version 5.1 and Batch Standard 1.1
The form used to submit paper claims Universal Claim Form
The person responsible for filling out the first section of the universal claim form Pharmacy Technician
Once a claim has been submitted, it is subject to editing for this Drug utilization review (DUR)
The prescription portion of a claim should include these components drug name, drug dosage, DEA number for controlled substances
All outpatient drugs are billed using this NDC number
The price a provider most frequently charges the general public for a specified drug Usual and customary price (U&C)
The three components recorded when completing the prescriber portion of a claim prescriber ID, last name, and phone number
An NPI number was formerly known as this NABP
The first insurance that a patient will use for claims is known as this Primary
The process that must occur after the primary plan is billed but before the secondary plan can be billed Adjudication
The methods used to price pharmacy prescriptions in the retail setting usual and customary (U&C), Average wholesale price (AWP), maximum allowable cost(MAC)
The fee for a pharmacy's professional services Dispensing fee
The current average dispensing fee charged by state Medicaid programs $4
In some cases, a claim can be routed to this before being sent on to the payer Switch vendor
When a prescription is filled, the pharmacy enters the prescription data into the internal system through one of these three methods A personal computer, a terminal, or a point-of-sale device
After a universal claim form is filled out, the patient needs to do this Read the certification statement on the back and sign the document
Created by: sarakiefer
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