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Insurance Fianl Exam
Review
| Question | Answer |
|---|---|
| Is there a specific date range that states this is when you should enroll in medicare? If you are late in doing this you are called | Yes Late Enrollee |
| For Medicaid, if you qualify for extra help with medical expenses do you have to re-apply every month? | No, it is granted yearly |
| Many states still require those receiving help through medicaid pay for some of their drug costs buy means of a ? | Copay |
| Part A | Inpatient hospital stays |
| Part A | Inpatient rehab facilities |
| Part A | Home health care |
| Hospice Care | Part A |
| Skilled nursing facility care (not long term) | Part A |
| Name the items on the medicare insurance card | Name, sex, Medical #, Part A and Part B and effective dates |
| Group of practicing doctors and other health care experts working to check and improve medicare are called? | Quality Improvement Organization |
| What part of medicare covers your bills if you are admitted into the hospital | Part A |
| Medicare Part C is also called | Medical Advantage Plan |
| This show all services and supplies billed to Medicare during a three month period | Medicare Summary Notice (MSN) |
| This is given to patient prior to treatment by a provider who thinks that a procedure will not be covered by Medicare because it will be deemed not reasonable and necessary | Advanced Beneficary Notice (ABN) |
| Groups of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare beneficiaries | Quality Improvement Organization QIO |
| This part covers prescription drugs | Part D |
| This part covers both preventive and regular services | Part B |
| Name the Five different kinds of medicare advantage plans | PPO, HMO, PFFS, MSA, SNP |
| Which tier would have a lower copay | Tier 1 |
| What information is needed to enroll in medicare | Personal ID, permanent street address, Info on medical card |
| What is the minimum number of plans for different sponsors that must be available in each region of the country? | Two |
| Which part of medicare has private companies contracting with CMS to offer medicare through their own policies | Part C |
| CMS | Centers for Medicare and Medicaid Services |
| Which type of plan gives patients financial incentive to stay within the network but also allows them to go outside the network | PPO |
| A foot doctor | Podiatrist POD |
| Skin Doctor | Dermatologist |
| Eye Doctor | Ophthalmologist |
| The doctor who would replace a knee or hip | Orthopedic |
| The specialty of a primary care physician. He/she is also known as a | internal medicine "Gate Keeper" |
| Gate Keeper | Who coordinates your health care |
| The BIN number - bank identification number - Identifies what ? | ID insurance plan. Where they route the money on the number ID's the insurance plan. |
| According to HIPAA - Documents / Medicare records that are generated and stored in the pharmacy belong to who | The Pharmacy that created them. |
| Who is required to follow HIPAA regulations? | Heath care clearing houses, health plans, and Health Care Providers. |
| The first comprehensive federal protection for the privacey of health information was the what? | HIPAA |
| What is considered PHI? | Birth date, License number, SSN, web site address, email and fingerprint |
| Under HIPAA health care providers are considered business associates? | No |
| Which of the following are considered PHI in regards to patient information | Written notes, oral communication and electronic transmission. |
| What % of people with private Health insurance have individual plan? | 10% |
| FEHB covers approximately now many people | 8 million. Federal Employees Health Benfits |
| What type of health insurance plan increases patient awareness of health care cost? | Consumer - Driven Health Plans |
| NDC# three sets of numbers represents | Labler, product, and Package size. |
| Professional fee for pharmacy prescription prosecessing | Dispensing Fee |
| The only pricing that is listed per unit | MAC |
| The agreement between a pharmacy and a pharmacy benefits manager | Participating Pharmacy Agreement |
| The formula for calculating inventory turnover rate | Cost of Goods sold/Average inventory on hand |
| Outdated Drugs | They are counted in inventory, Can sometimes be returned, should be pulled off the shelves |
| Who is the third party? | the Payer |
| When a patient with prescription insurance never comes to pick up the prescription that you filled for them? | Reverse transaction, reverse claim, and put back on shelve |
| What DAW code do you use when the patients insists on the brand name even though the Doctor said it was okay to substitute the generic | DAW - 2 |
| What is the DAW Code - When the doctor indicated dispense as written instead of giving the generic | DAW - 1 |
| What is the reason for an insurance company having a formulary | Control Cost |
| Missing invaild patient name might be due to this error | Wrong Birthdate |
| Prior authorization is required for | High cost meds, non formulary meds, and cosmetic meds. |
| High Dose alert | is Clinical |
| What type of health insurance plan pays specialists according to a contractual agreement? | HMO |
| Carge higher costs for out of network providers? | PPO and POS |
| What plan does not normally cover preventive care | Idemity Insurance |
| What plan will only pay if you stay within the network | HMO |
| When completing the patient information on a claim what information do you need | Cardholder ID, Group ID, Patient relationship |
| What information remains the same for each refill on a prescription | Patient ID number, Pharmacy ID number, and Name of the provider |
| When completing the prescriber information you need to record what | prescriber phone number, prescriber name and prescriber ID |
| When recording the patient information what do you need to include | Patient name, Patient's address, and Patient's gender. |
| Which is te first ste in completing claim | recording the patient information |
| If prior authorization is denied, what should the pharmacy technician do? | Tell the patient they can pay cash and Have the pharmacist contact the doctor for an alternative medication |
| Can a patient has about their insurance plan? | Yes |
| Pre-editing | Claims before submitting them to a PBM can identify data fields that are missing and invalid |
| PMPM | Per member per month |
| For prior authorization what information is needed | Pharmacist name, source of information(why they need it), diagnosis, and physician. |
| When recording the prescription information, you must include the following | Drug name, DEA number (if applicable), and drug dose. |
| A charge back | Insurance company makes error. Wants money back from pharmacy |
| Billing cycle includes which of the following steps | Patient interview, prescription receipt, and filling the prescription. |
| The final step in the billing cycle is? | Collections and problem resolution |
| What document is received by the pharmacy that show the detail for each claim? | Explanation of benefits and remittance advice. |
| This is the person who performs statistical analyses to determine what premiums need to be earned by the insurance company to cover expenses. | Actuary |
| Three of the four services within insurance pans that are often managed separately | Eye care, dental care, mental health care |
| Patient cost sharing comes in three forms. They are | Deductables, copays, coinsurance |
| Capitation payments and withholding funds are used in what type of managed care settings | HMO |
| PBM's control costs in 10 different ways. These include | Cost sharing and Therapeutic Interchange |
| DUR | Drug utilization Review |
| MAC | Max allowable Cost |
| The Pharmacy & Theraputic Committee | Develops the formularies for PBM's and hospitals. |
| DAW | Are nine codes that explain why a certain multiple source product was used or not used |
| CDHP | Consumer Driven Health Plan |
| Coordination of Benefits | A provision that ensures that when a patient is covered under more te benefits are paid, but without duplication |
Created by:
Agoddess
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