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chapter7
| Question | Answer |
|---|---|
| audit | a challenge on a reimbursement from a PBM or insurance provider on a prescription claim that has been previously processed |
| average wholesale price (AWP) | the average price that wholesalers charge the pharmacy for a drug |
| certificate of medical necessity | form to be completed and signed by the prescriber for Medicare Part B insurance payment for diabetic supplies |
| charge-back | a rejection of a prescription claim by a PBM or an insurance provider that must be investigated and resolved |
| co-insurance | a percentage-based insurance plan in which the patient must pay a certain percentage of the prescription price |
| computer | an electronic device for inputting, storing, processing, and/or outputting information |
| coordination of benefits (COB) | online billing of both a primary and a secondary insurer |
| co-payment (co-pay) | the amount that the patient is to pay for each prescription as determined by insurance |
| credit card | a method of online payment that is a type of loan, either paid totally at the end of the month or partially with a finance charge added |
| database management system (DBMS) | application that allows one to enter, retrieve, and query records |
| days' supply | the duration of time (number of days) a dispensed medication will last a patient; required on drug claims submitted for insurance billing |
| debit card | a method of online cash payment that instantly deducts the cost of the purchase from the customer's bank account |
| deductible | an amount that must be paid by the insured before the insurance company considers paying its portion of a medical or drug cost |
| dietary supplement | a category of nonprescription drugs that includes vitamins, minerals, and herbals that are not directly regulated by the FDA like OTC drugs |
| discount | a reduced price |
| donut hole | insurance coverage gap in Medicare Part D programs by which the patient must pay a higher portion of the cost of the medication |
| dual co-pay | insurance coverage in which a patient pays one co-pay for brand name drugs and a lower co-pay for generic drugs |
| dumb terminal | a computer device that contains a keyboard and a monitor but does not contain its own storage and processing capabilities |
| durable medical equipment (DME) | medical equipment such as hospital beds, wheelchairs, canes, or crutches that may be covered under Medicare Part B insurance |
| Flex card | a medical and prescription insurance credit card |
| gross profit | the difference between the purchase price and the selling price; also called markup |
| health insurance | coverage of incurred medical costs such as physician visits, laboratory costs, and hospitalization |
| inventory | the entire stock of products on hand for sale at a given time |
| inventory turnover rate | the amount of time the average drug inventory will be replaced during a 12-month period; most pharmacies replace inventory every two to four weeks |
| inventory value | the total value of the entire stock of products on hand for sale on a given day |
| just-in-time (JIT) purchasing | frequent purchasing in quantities that just meet supply needs until the next ordering time |
| markup | the difference between the purchase price and the selling price; also called gross profit |
| Medicaid | a state government health insurance program for low-income and disabled citizens |
| Medicare Part D | a voluntary insurance program that provides partial coverage of prescriptions primarily for patients who are eligible for Medicare |
| nondurable medical supplies | consumable, disposable items that can only be used by one patient for a specific purpose |
| online adjudication | real-time insurance claims processing via wireless telecommunications |
| out of stock (OOS) | a situation in which the pharmacy does not have the prescribed drug in inventory |
| over-the-counter (OTC) drug | a medication that the FDA has approved for sale without a prescription; another name for nonprescription drug |
| partial fill | a situation in which the pharmacy cannot completely fill the prescribed quantity written on the prescription |
| perpetual inventory record | a record that accounts for each unit of Schedule II drug dispensed or received |
| prescription benefits manager (PBM) | a company that administers drug benefits from many insurance companies |
| posting | the process of reconciling the invoice and updating inventory at time of receipt |
| preferred drug list | a formulary provided by an insurance company that indicates preferred prescription generic and brand name drugs and their corresponding co-pays |
| prime vendor purchasing | an agreement made by a pharmacy for a specified percentage or dollar volume of purchases |
| prior authorization (PA) | approval for coverage of a high-cost medication or a medication not on the insurer's approved formulary |
| private insurance | coverage for medical or prescription costs provided by an employer or purchased by an individual |
| profit | the amount of revenue received that exceeds the expense of the sold product, services, and overhead |
| purchasing | the ordering of products for use or sale by the pharmacy |
| receipt | a printout that is a proof of purchase |
| receiving | a series of procedures for accepting the delivery of products to the pharmacy from a wholesaler or centralized warehouse |
| remote computer | a minicomputer or a mainframe that stores and processes data sent from a dumb terminal |
| Schedule V drug | a medication with a low potential for abuse and a limited potential for creating physical or psychological dependence; available in most states without a prescription |
| sharps | any needle, lancet, scalpel blade, or other medical equipment that could cause a cut or puncture |
| smart terminal | a computer that contains its own storage and processing capabilities |
| smurfing | a practice that occurs when a patient is paid cash by an individual to illegally purchase pseudoephedrine from more than one pharmacy |
| tiered co-pay | insurance coverage in which the patient has an escalating cost or co-pay, depending on whether the filled prescription is a generic drug, a preferred brand name drug, or a nonpreferred brand name drug |
| Tricare | a federal government health insurance program for active and retired military personnel and their dependents |
| uninsured | patients with no insurance who must pay out-of-pocket for medical and/or prescription costs |
| usual and customary charges | the total cost of dispensing a prescription to the general public; a pharmacy cannot bill government insurance programs more than the usual and customary charge |
| wholesaler purchasing | the ordering of drugs and supplies from a local vendor who delivers the product to the pharmacy on a daily basis |
| workers' compensation | insurance provided for a patient with a medical injury from a job-related accident; also called workers' comp |
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softcrylic
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