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Insurance Fianl Exam


Is there a specific date range that states this is when you should enroll in medicare? If you are late in doing this you are called Yes Late Enrollee
For Medicaid, if you qualify for extra help with medical expenses do you have to re-apply every month? No, it is granted yearly
Many states still require those receiving help through medicaid pay for some of their drug costs buy means of a ? Copay
Part A Inpatient hospital stays
Part A Inpatient rehab facilities
Part A Home health care
Hospice Care Part A
Skilled nursing facility care (not long term) Part A
Name the items on the medicare insurance card Name, sex, Medical #, Part A and Part B and effective dates
Group of practicing doctors and other health care experts working to check and improve medicare are called? Quality Improvement Organization
What part of medicare covers your bills if you are admitted into the hospital Part A
Medicare Part C is also called Medical Advantage Plan
This show all services and supplies billed to Medicare during a three month period Medicare Summary Notice (MSN)
This is given to patient prior to treatment by a provider who thinks that a procedure will not be covered by Medicare because it will be deemed not reasonable and necessary Advanced Beneficary Notice (ABN)
Groups of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare beneficiaries Quality Improvement Organization QIO
This part covers prescription drugs Part D
This part covers both preventive and regular services Part B
Name the Five different kinds of medicare advantage plans PPO, HMO, PFFS, MSA, SNP
Which tier would have a lower copay Tier 1
What information is needed to enroll in medicare Personal ID, permanent street address, Info on medical card
What is the minimum number of plans for different sponsors that must be available in each region of the country? Two
Which part of medicare has private companies contracting with CMS to offer medicare through their own policies Part C
CMS Centers for Medicare and Medicaid Services
Which type of plan gives patients financial incentive to stay within the network but also allows them to go outside the network PPO
A foot doctor Podiatrist POD
Skin Doctor Dermatologist
Eye Doctor Ophthalmologist
The doctor who would replace a knee or hip Orthopedic
The specialty of a primary care physician. He/she is also known as a internal medicine "Gate Keeper"
Gate Keeper Who coordinates your health care
The BIN number - bank identification number - Identifies what ? ID insurance plan. Where they route the money on the number ID's the insurance plan.
According to HIPAA - Documents / Medicare records that are generated and stored in the pharmacy belong to who The Pharmacy that created them.
Who is required to follow HIPAA regulations? Heath care clearing houses, health plans, and Health Care Providers.
The first comprehensive federal protection for the privacey of health information was the what? HIPAA
What is considered PHI? Birth date, License number, SSN, web site address, email and fingerprint
Under HIPAA health care providers are considered business associates? No
Which of the following are considered PHI in regards to patient information Written notes, oral communication and electronic transmission.
What % of people with private Health insurance have individual plan? 10%
FEHB covers approximately now many people 8 million. Federal Employees Health Benfits
What type of health insurance plan increases patient awareness of health care cost? Consumer - Driven Health Plans
NDC# three sets of numbers represents Labler, product, and Package size.
Professional fee for pharmacy prescription prosecessing Dispensing Fee
The only pricing that is listed per unit MAC
The agreement between a pharmacy and a pharmacy benefits manager Participating Pharmacy Agreement
The formula for calculating inventory turnover rate Cost of Goods sold/Average inventory on hand
Outdated Drugs They are counted in inventory, Can sometimes be returned, should be pulled off the shelves
Who is the third party? the Payer
When a patient with prescription insurance never comes to pick up the prescription that you filled for them? Reverse transaction, reverse claim, and put back on shelve
What DAW code do you use when the patients insists on the brand name even though the Doctor said it was okay to substitute the generic DAW - 2
What is the DAW Code - When the doctor indicated dispense as written instead of giving the generic DAW - 1
What is the reason for an insurance company having a formulary Control Cost
Missing invaild patient name might be due to this error Wrong Birthdate
Prior authorization is required for High cost meds, non formulary meds, and cosmetic meds.
High Dose alert is Clinical
What type of health insurance plan pays specialists according to a contractual agreement? HMO
Carge higher costs for out of network providers? PPO and POS
What plan does not normally cover preventive care Idemity Insurance
What plan will only pay if you stay within the network HMO
When completing the patient information on a claim what information do you need Cardholder ID, Group ID, Patient relationship
What information remains the same for each refill on a prescription Patient ID number, Pharmacy ID number, and Name of the provider
When completing the prescriber information you need to record what prescriber phone number, prescriber name and prescriber ID
When recording the patient information what do you need to include Patient name, Patient's address, and Patient's gender.
Which is te first ste in completing claim recording the patient information
If prior authorization is denied, what should the pharmacy technician do? Tell the patient they can pay cash and Have the pharmacist contact the doctor for an alternative medication
Can a patient has about their insurance plan? Yes
Pre-editing Claims before submitting them to a PBM can identify data fields that are missing and invalid
PMPM Per member per month
For prior authorization what information is needed Pharmacist name, source of information(why they need it), diagnosis, and physician.
When recording the prescription information, you must include the following Drug name, DEA number (if applicable), and drug dose.
A charge back Insurance company makes error. Wants money back from pharmacy
Billing cycle includes which of the following steps Patient interview, prescription receipt, and filling the prescription.
The final step in the billing cycle is? Collections and problem resolution
What document is received by the pharmacy that show the detail for each claim? Explanation of benefits and remittance advice.
This is the person who performs statistical analyses to determine what premiums need to be earned by the insurance company to cover expenses. Actuary
Three of the four services within insurance pans that are often managed separately Eye care, dental care, mental health care
Patient cost sharing comes in three forms. They are Deductables, copays, coinsurance
Capitation payments and withholding funds are used in what type of managed care settings HMO
PBM's control costs in 10 different ways. These include Cost sharing and Therapeutic Interchange
DUR Drug utilization Review
MAC Max allowable Cost
The Pharmacy & Theraputic Committee Develops the formularies for PBM's and hospitals.
DAW Are nine codes that explain why a certain multiple source product was used or not used
CDHP Consumer Driven Health Plan
Coordination of Benefits A provision that ensures that when a patient is covered under more te benefits are paid, but without duplication
Created by: Agoddess