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Chapter 1
Medical Insurance Study Guide
| Question | Answer |
|---|---|
| In what area might a pharmacy technician insurance specialist work? | Large pharmacy practices where individuals specialize in various task or small pharmacy practice where the same individual may handle many roles. |
| What is normally included in medical insurance policies? | Prescription drug, primary medical services, emergency care, surgery and preventive care visits etc. |
| Workers' compensation benefits vary according to ______ law. | State |
| List three preventive medical services that would be covered by health plans. | Annual exams, pediatric vaccines, prenatal care, routine cancer screening |
| In what ways might a physician submit a prescription to the pharmacy? | Call, Fax, Electronic Prescribing |
| What is remittance advice? | Document that comes to a pharmacy showing the details for a claim, also known as explanation of benefits. |
| What components does a pharmacy claim identify? | The policyholder, the prescriber, the pharmacy and the medication |
| During which step of the pharmacy billing cycle is on electronic data interchange sent? | Step 4 Pharmacy Claim Transmittal |
| Approximately how much per year do Americans spend on outpatient prescriptions? | $180 Billion |
| What is the time period for must claims to be due after the data of service? | 30-60 days |
| What do health plans agree to pay for medical services? | Benefits |
| What is a lifetime limit? | The monetary amount after which a plan's benefits end, also known as maximum benefit limit. |
| What are the different types of government program insurances? | Medicare, Medicaid, TRICARE, CHAMPVA, Workers' Compensation |
| What is CHAMPVA? | A program for veterans with permanent service-related disabilities and their dependents. It also covers surviving spouses and dependent children of veterans who died from service-related disabilities. |
| What is preexisting conditions. | A medical condition that was diagnosed before the policy was written. |
| List three good communication skills that a pharmacy technician needs when dealing with patients. | Pleasant tone, Friendly attitude, and helpful manner. |
| What may happen if an inaccurate claim is filed? | Lower payment or claim denied or delayed, disruption of other work and problematic customer relation |
| What is medicare? | A federal health plan that covers most citizens aged 65 and over, people with disabilities, people with end-stage renal disease and dependent widows. |
| Managed care was primarily introduced for what reason? | Control Cost |
| What is the preferred drug list? | A list containing the FDA approved brand-name and generic medications a plan covers. |
| What is the list of covered services that a health plan issues to the policyholder? | Schedule of Benefits |
| What is Step 1 of the billing cycle? Brief description | Receipt of Prescription Pharmacy actually receiving the prescription form the patient or doctor. |
| What is step 2 of the billing cycle? Brief description. | Patient Interview Interview the patient to see if they are new or not. If new patient then enter the patient demographics in the computer. |
| What is step 3 of the billing cycle? Brief description. | Filling of Prescription the actual filling of the prescription, counting the pills. |
| What is step 4 of the billing cycle? Brief descrpiton. | Pharmacy Claim Transmittal Information is sent to payer to permit a payment decision, most claims are sent electronically by EDI |
| What is step 5 if the billing cycle? Brief description | Payer Adjudication Claim is adjudication to the payer, payer's processing determines whether the drug is covered by the patient's plan and is being utilized properly. |
| What is step 6 of the billing cycle? Brief description | Point-of-Sale Payment patient receives the prescription and the pharmacy receives money from the patient for the prescription. |
| What is step 7 of the billing cycle? Brief description | Calculation of Payer Claim Balance payer starts internal processing of the claim for payments to the pharmacy, amount patient paid is subtracted form the total the payer specified as intended payment. |
| What is step 8 of the billing cycle? Brief description | Accounts Receivable Follow-Up Balance sure within 30 to 60 days after date of service |
| What us step 9 of the billing cycle? Brief description | Payment Processing payment may be received electronically, directly in the bank account, or by check pharmacy also receives a remittance advice showing detail for each claim. |
| What is the step 10 to the billing cycle? Brief description | Collection and Problem Resolution fix any problems and collect unpaid balances |
Created by:
gfoster32
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