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Module 9
Section 5:Claims reconciliation and ensuring payment
| Question | Answer |
|---|---|
| Which document is used to reconcile prescription claims with pharmacy benefit manager payments? | A remittance advice |
| Which four questions are addressed by claim management systems? | Was any of the adjudicated claim paid? Was the claim paid at the rate indicated by the adjudication response? Was the claim paid at the correct contract rate? Was the claim paid in full? |
| If a pharmacy benefit manager determines a claim was paid in error, they may bill the questioned amount back to the pharmacy. What is this called? | Chargeback |
| Why is it important for a pharmacy technician to follow procedures related to documenting partial fills? | To avoid billing the pharmacy benefit manager twice for the same prescription |
| Why is it important to document that a patient has received a prescription? | Without proper documentation, a payer could allege that the patient never received the prescription and attempt to recover payment for that prescription. |
| What happens if a medication is not picked up by the patient within a specified period? | The medication is returned to the shelf. If the medication has been charged to the patient or third party, the charge is reversed. |
| Why do pharmacy benefit manager (PBM) auditors examine pharmacy records? | To ensure there are prescriptions to cover all claims submitted. To ensure accuracy of information, including Dispense as Written codes, submitted on claims. To ensure that a patient or patient's representative has signed for all prescriptions that were billed to the PBM. |
Created by:
PRO Teacher
Lane.Wendy
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