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insurance terms

insurance terminology pharm tech

out of pocket out of pocket expenses are the costs that are considered the responsibility of the patient, including non-covered items, deductibles, and copays
third-party payer an organization other than the patient (first party) or pharmacy / health care provider (second party) involved in the financing of personal health services including, but not limited to, prescription medication
fraud can be broadly defined as an act of deliberate deception performed to acquire an unlawful benefit. In a pharmacy, that may include billing for a medication or device the patient did not receive, or over billing for a medication or device
bank identification number BIN; on a health insurance card, a BIN is a six digit number used to specify a specific plan from a carrier making it easier for the PBM to process your prescription online. The name is a holdover from early electronic banking terminology, no actual bank is involved.
group number a group number identifies your group, or business, from other groups, or businesses, who are insured by the same insurance company
member number is a number in correlation to the relationship to the family member that provides the insurance. Typically, the individual that is primarily insured has a member number of "00" or "01" and the next number is reserved for their spouse, "01" or "02". Any children are usually listed consecutively from oldest to youngest.
Processor Control Number PCN; is a secondary identifier for insurance that may be used in the routing of pharmacy transactions by the processor to aid in the receipt and adjudication of prescription claims.
PCN an alphanumeric number defined by the PBM / processor, as the identifier is unique to their business needs; there is no official registry of PCN's
private insurance plans that customers receive through their employer (or their family member's employer), or through individual purchases
public insurance insurance either provided by or subsidized by the government, such as Medicare and Medicaid
managed care a term used to describe most insurance policies; used to describe a variety of techniques intended to reduce the cost of health benefits and improve the quality of care
health maintenance organization HMO; covers care provided by health professionals who have signed up with the HMO, and have agreed to treat patients according to the HMO's policies
preferred provider organization PPO; an insurance plan in which only authorized health care professionals and hospitals treat patients for an agreed upon rate
exclusive provider organization EPO; an insurance plan in which only authorized health care professionals and hospitals treat patients for an agreed upon rate. This plan is more exclusive than a PPO.
Centers for Medicare and Medicaid Services CMS; federal agency within the Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards
Medicare federal health insurance program for patients 65 years and older, some younger patients with disabilities, and some people with permanent kidney failure (end-stage renal disease)
ESRD end-stage renal disease
Medicaid joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary state to state. Some people may be covered by Medicaid and Medicare
National Council for Prescription Drug Programs NCPDP; nonprofit organization that creates national standards for electronic health care transactions used in prescribing, dispensing, monitoring, managing, and paying for medications and pharmacy services. NCPDP also develops standardized business solutions and best practices that safeguard patients
prior authorization if a med is not normally covered by an insurance, is a particularly high dose, has significant risk potential, is being used to treat or ameliorate off-label disease(s) / condition(s), or is not usually recommended for a particular age or gender, the physician and / or the pharmacy may need to acquire prior authorization in order to get the insurance to cover the medication
coordination of benefits determining which insurance should be considered primary, secondary, tertiary, etc is sometimes referred to as coordination of benefits; used commonly when one of the insurance plans involves Medicare
adjudication term used in the insurance industry to refer to the process of paying claims submitted, or denying them after comparing claims to the benefit or coverage requirements
remittance advice RA; document sent to the pharmacy by the insurance company providing the details of a paid claim. Also referred to as explanation of benefits (EOB)
fee-for-service reimbursement a payment method in which providers receive payment for each service rendered
PBM pharmacy benefit manager; third party administrator of prescription drug programs
Created by: DbaileyC



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