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Ch.1 Insurance
Becoming a Pharm Tech Insurance Specialist
| Question | Answer |
|---|---|
| In an average year, Americans spend this much on outpatient prescription medications. This amount is growing and is expected to continue to increase. | Around $180 billion |
| Some contracts do not demand a deductible, and provide this. It begins with the first charge of the year. | First-dollar-coverage |
| Insurance term referring to appropriate medical treatment given under generally accepted standards of medical practices | Medically necessary |
| Medically necessary procedures are approved by this | An appropriate federal regulatory agency, such as the FDA |
| Policies that have this usually provide coverage for a selection of prescription medications | Pharmacy benefit |
| A fee paid monthly to a health plan by a person who buys medical insurance | Premium |
| List containing the FDA-approved brand-name and generic medications a plan covers | Formulary |
| Method of supervising medical care with the goal of ensuring that patients get needed services in the most appropriate, cost-effective setting | Managed care |
| Workers' Compensation benefits vary according to this | State law |
| Low-income people who can't afford health insurance can be covered by this | Medicaid |
| Federal health plan that covers most citizens aged 65 or over | Medicare |
| Program for veterans with permanent service-related disabilities | CHAMPVA |
| Errors in the claim process can result in this. | Slowed or denied payments |
| The process of checking to verify that each claim reimbursed by a payer is correct according to the expected payment | Reconciliation |
| This is as important as knowing about specific forms, codes, and regulations | Communication skills |
| Give examples of preventive medical services | Prenatal care, annual physical exams, pediatric and adolescent immunizations, and routine cancer screening procedures such as mammograms |
| Document that comes to a pharmacy showing the details for a claim. Also known as an explanation of benefits. | Remittance advice |
| The final step in the pharmacy billing cycle | Collections and problem resolution |
| Describe Step 6 of the pharmacy billing process: Point-of-Sale Payment | Give the patient the prescription and collect payment. Pharmacist consults with patient. |
| This step of the pharmacy billing process involves internal processing of the claim for payment to the pharmacy | Step 7: Calculation of Payer Claim Balance |
| Payments made by a health plan for medical services | Benefits |
| A medical condition a policyholder was diagnosed with before a policy was written | Preexisting condition |
| Monetary amount after which a plan's benefits end, also known as a maximum benefit limit | Lifetime limit |
| Copayments are always paid at this time | At the time of service |
| Payer's processing of claim data to decide whether a drug is covered by the patient's plan and is properly utilized | Adjudication |
| An insurance policy that contains a list of covered medical services | Schedule of benefits |
| Percentage of the fees owed by the policyholder | coinsurance |
| The use of software to transmit a prescription order | Electronic prescribing |
Created by:
sarakiefer
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