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CHAPTER 14
FINANCIAL ISSUES
| Question | Answer |
|---|---|
| PHARMACY BENEFIT MANAGER (PBM) | a company that administers drug benefit programs |
| ARGUS,CATAMARAN,CIGNA HEALTHCARE,CVS/CAREMARK, EXPRESS SCRIPTS,HUMANA,MEDIMPACT, SXC | names of some pharmacy benefit managers |
| CO-INSURANCE | an agreement for cost-sharing between the insurer and the insured |
| CO-PAY | the portion of the price of medication that the patient is required to pay |
| DUAL CO-PAY | co pays that have two prices: one for generic and one for brand medications |
| MAXIMUM ALLOWABLE COST (MAC) | the maximum price per tablet (or other dispensing unit) an insures or PBM will pay for a given product |
| ONLINE AJUDICATION | the resolution of prescription coverage through the communication of the pharmacy computer with the third-party computer |
| UCR | the maximum amount of payment for a given prescription, determined by the insurer to be a usual and customary and reasonable price |
| DEDUCTIBLE | a set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses |
| FORMULARY | a list of medications covered by third-party plans |
| PRESCRIPTION DRUG BENEFIT CARDS | cards that contain third-party billing information for prescription drug purchases |
| TIER | categories of medications that are covered by third-party plans |
| HEALTH MAINTENANCE ORGANIZATION(HM0);POINT OF SERVICE PROGRAM (POS) AND PREFERRED PROVIDER ORGANIZATION (PP0S) | Managed care programs |
| MANAGED CARE PROGRAMS | provide all necessary medical services usually including prescription coverage in return for a monthly premium and co-pays |
| HMOs | a network of providers for which costs are covered inside but not outside of the network |
| POS | a network of providers where the patient's primary care physician must be a member and costs outside the network may be partially reimbursed |
| PPO | 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. offers the most flexibility |
| MEDICARE AND MEDICAID | PUBLIC HEALTH INSURANCE PLANS |
| MEDICARE | a federal program covering people aged 65 and over,disabled people under age 65 and people with kidney failure. |
| MEDICARE PART A | covers inpatient hospital expenses for patients who meet certain conditions, may also cover hospice expenses |
| MEDICARE PART B | covers doctors services as well as some other medical services that are covered by Part A. medicare beneficiaries who pay a monthly premium for this medical coverage are covered by _____________ |
| MEDICARE PART D | medicare prescription drug plan, requires participants to pay a montly premium and also meet certain deductibles and co-payments |
| MEDICAID | a federal state program for eligible individuals and families with low income, can qualify for HMO programs |
| MEDICAID | a federal state program, administered by the states, providing health care for the needy |
| MEDICARE | a federal program providing health care to people with certain disabilities or who are over 65, includes basic hospital insurance, voluntary medical insurance, and voluntary prescription drug insurance |
| PATIENT ASSISTANCE PROGRAMS | manufacturer sponsored prescription drug programs for the needy |
| WORKERS' COMPENSATION | an employer compensation program for employees accidentally injured on the job |
| PATIENT ASSISTANCE PROGRAM | are programs offered by manufacturers to help needy patients who require medication they cannot afford and do not insurance coverage |
| COORDINATION OF BENEFITS | households with two adults have two different health insurance plans |
| COORDINATION OF BENEFITS | allows for patients to have maximum coverage for health-care expenses through both health insurance plans. |
| ONLINE AJUDICATION | the technician uses the computer to determine the appropriate third party exact coverage for each prescription |
| ONLINE AJUDICATION | process the insurer sometimes rejects the clam as submitted |
| NO DAW | 0 |
| DAW HANDWRITTEN | 1 |
| PATIENT REQUESTED BRAND | 2 |
| PHARMACIST SELECTED BRAND | 3 |
| GENERIC NOT IN STOCK | 4 |
| BRAND NAME DISPENSED BUT PRICED AS GENERIC | 5 |
| N/A | 6 |
| SUBSTITUTION NOT ALLOWED, BRAND MANDATED BY LAW | 7 |
| GENERIC NOT AVAILABLE | 8 |
| OTHER | 9 |
| INVALID PERSON CODE | does not match the person code for the patient with same sex and birth date |
| REFILLS NOT COVERED | many managed care health programs require mail order pharmacies to fill prescription |
| NDC NOT COVERED | type of rejection is common with Medicaid programs and managed care programs with closed formularies |
| UNIVERSAL CLAIM FORM | standardized form accepted by many insurers |
| HCFA 1500 | CMS-1500 form was formally called ____________ |
| CMS 1500 FORM | the standard form used by health care providers to bill for services, including disease state management services and MTM serivices |
| PDP AND NPI | in order to bill prescription for MTM services the pharmacist or pharmacy offering the services must be enrolled as a provider for patient's ________ and also have _________________ |
| CMS 10114 FORM | the standard six-page form used by health care providers to apply for a National Provider Identifier (NPI) |
| MEDICATION THERAPY MANAGEMENT SERVICES | services provided to some Medicare beneficiaries who are enrolled in Medicare Part D and who are taking multiple medications who have certain disease |
| CURRENT PROCEDURAL TERMINOLOGY CODES (cpt) | identifiers used for billing pharmacist provided MTM services |
| NATIONAL PROVIDER IDENTIFIER (NPI) | the code assigned to recognized health care providers; needed to bill MTM services |
| 99605 | CPT codes used for a first encounter with patient, 1-15 minute increments |
| 99606 | CPT codes used for follow up, may be billed 1-15 minute increments |
| 9907 | add on CPT code to be used with 99605 or 99606 when additional 15 minute increments of time spent face-to face with patienT |
| PRESCRIPTION DRUG PLANS (PDP) | third party programs for Medicare Part D |
Created by:
mragay2007