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WTI Insurance Ch. 7

Medical Insurance for Pharmacy Techs

True or False: Receiving an answer to online adjucation takes about 15 minutes with today’s high-speed computers and networks. False
True or False: Edits are also performed to check the accuracy and safety of information contained in the claim. True
True or False: Common administrative edits include a Therapeutic Duplication check. False
True or False: A High Dollar edit prevents claims that exceed a normally expected dollar threshold from continuing to process without correction of data from pharmacy or override for special circumstances. True
True or False: There are about the same number of administrative and safety edits. False
True or False: There are about the same number of administrative and safety edits. False
True or False: Edits may still be pending when a prescription is dispensed. False
True or False: Today, remittance advices are transmitted electronically. True
True or False: Medicare offers free software for remittance advices. True
True or False: An adjustment occurs when the amount charged on a claim is equal to the amount paid. False
True or False: Codes for adjustments are only updated one time per year. False
Approximately how long does the online adjudication process take? a matter of seconds
What program reviews incoming claims agains the criteria that must be met for a payer to provider reimbursement for a prescription? the payer’s claims processing program
Which criteria do edits check? the eligibility of an individual & whether or not a drug is covered by the patient’s plan
Which of the following is not a common type of administrative edit? time interval
What is a common type of safety edit? drug-drug interaction, days’ supply/maximum quantity, age/gender contraindications
What are the correct two categories of edits? administrative and safety
What type of edit might indicate to a pharmacist that a patient is taking two doses of medication in a day instead of one? refill too soon
Under what type of administrative edit might a patient be able to get a brand drug if they are allergic to a component in generic drug? step therapy
What can a pharmacy do if it believes that the prescribed medication is safe for a patient after receiving a safety edit? override the edit
If an edit cannot be resolved, what financial obligation will fall on the patient? the full cost of the prescription
Created by: lrhamyWTI