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Chapter 7 insurance
Processing Claims and Reconciling Accounts
| Question | Answer |
|---|---|
| The process that a payer follows to examine claims and determine correct payments | Adjudication |
| How long it takes to process an online claim | Seconds |
| Checks that evaluate prescription claims for errors and missing information, and that ensure compliance with the benefit plan and industry standards | Edits |
| Edits fall into these two categories | Administrative and safety |
| Examples of administrative edits | Eligibility, dosage, duplicate claim, refill too soon, coordination of benefits, high dollar, nonformulary |
| Edit used to encourage the use of less expensive, similarly effective generic medications before considering coverage of higher cost brand name products | Step Therapy |
| Checks required when a prescription request exceeds a certain quantity limit or dosage or there is a potentially dangerous drug interaction | Safety Edits |
| Before a prescription can be dispensed, what must be done with the edits? | Edits must be resolved and the claim must be resubmitted |
| A document sent by the payer to the pharmacy explaining the actions taken and status of a claim. It provides the pharmacy with the results of claim adjudication and indicates the amount of reimbursement that will be paid. | Remittance Advice |
| Free software offered by Medicare that permits pharmacies to print the electronic remittance in a format that can be easily understood | Medicare Remit Easy Print (MREP) |
| This occurs when the amount charged on a claim is not equal to the amount paid | Adjustment |
| Mandatory codes used to specify reasons for adjustments to claims such as: PR(patient responsibility) or CO(contractual obligation) | Claim Adjustment Group Codes |
| The best time to collect payments due from patients | When they are picking up their prescriptions |
| One of the primary roles of the pharmacy technician in processing, resubmitting, and finalizing claims | To provide good customer service to the patient |
| The act of comparing the total charges and amount owed with the reimbursement received from the insurer and the patient. Also referred to as "balancing the account" | Account Reconciliation |
| Pharmacies must keep records of all claim submissions and denials this long | Until the final resolution of the claim is reached |
| Documents used to identify patient accounts with overdue outstanding balances | Aging Reports |
| Reasons why a patient may not pay their bill | They believe their bill is incorrect, they did not receive their bill, they cannot afford to pay their bill |
| Efforts made to collect overdue payments must follow these guidelines | Fair Debt Collection Practices Act of 1977 and the Telephone Consumer Protection Act of 1991 |
| To detect possible fraud, such as dispensing expired prescription drugs or altering prescriptions, payers conduct these | Audits |
| These audits are performed on-site at the pharmacy and typically include the review of computerized claim records, signature logs, and inventory | Field audits |
| Edits that indicate that additional information is needed to process the claim or that some information has been entered incorrectly | Administrative Edits |
| ASC X12N 835 Pharmacy Remittance Advice Template is compliant with this law | HIPAA |
| These can be used to provide further explanation of an adjustment code, but they are not mandatory | Remittance Advice Remark Codes (RARC) |
Created by:
sarakiefer
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