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Ch.6 Insurance
Claim Preparation and Transmission
| Question | Answer |
|---|---|
| Most claims are filed this way | Electronically |
| The beginning point for filing a claim. This information is vital to a successful claim submission. | Recording correct patient information |
| The prescriber ID number may comprise these two different identifiers | NPI number and DEA number |
| A dependent child's insurance coverage that is determined by the parent whose date of birth is earlier in the calendar year is known as this | Birthday Rule |
| A set of NCPDP codes used to inform third parties of the reason why a brand or generic product was used to fill a prescription | Dispense As Written (DAW) codes |
| The greatest unit price that a payer or PBM will pay | MAC (maximum allowable cost) |
| This enables providers to submit electronic pharmacy claims in an online real-time environment | Real-time claims management systems |
| The HIPAA standard for electronic retail pharmacy drug claims | NCPDP Telecommunications Standard Version 5.1 and Batch Standard 1.1 |
| The form used to submit paper claims | Universal Claim Form |
| The person responsible for filling out the first section of the universal claim form | Pharmacy Technician |
| Once a claim has been submitted, it is subject to editing for this | Drug utilization review (DUR) |
| The prescription portion of a claim should include these components | drug name, drug dosage, DEA number for controlled substances |
| All outpatient drugs are billed using this | NDC number |
| The price a provider most frequently charges the general public for a specified drug | Usual and customary price (U&C) |
| The three components recorded when completing the prescriber portion of a claim | prescriber ID, last name, and phone number |
| An NPI number was formerly known as this | NABP |
| The first insurance that a patient will use for claims is known as this | Primary |
| The process that must occur after the primary plan is billed but before the secondary plan can be billed | Adjudication |
| The methods used to price pharmacy prescriptions in the retail setting | usual and customary (U&C), Average wholesale price (AWP), maximum allowable cost(MAC) |
| The fee for a pharmacy's professional services | Dispensing fee |
| The current average dispensing fee charged by state Medicaid programs | $4 |
| In some cases, a claim can be routed to this before being sent on to the payer | Switch vendor |
| When a prescription is filled, the pharmacy enters the prescription data into the internal system through one of these three methods | A personal computer, a terminal, or a point-of-sale device |
| After a universal claim form is filled out, the patient needs to do this | Read the certification statement on the back and sign the document |
Created by:
sarakiefer
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