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Chapter 7 insurance

Processing Claims and Reconciling Accounts

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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