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Ch. 13 Terms
Ch. 13 Billing & Inventory Management
| Term | Definition |
|---|---|
| Adjudication | Electronic insurance billing for medication payment. |
| Average Wholesale Price (AWP) | The average price at which a drug is sold; the data are complied from info provided by manufacturers, distributors, and pharmacies; the AWP is often used in calculations related to medication reimbursement. |
| Civilian Health & Medical Program of the Department of Veterans Affairs (CHAMPVA) | A program for veterans with permanent service-related disabilities and their dependents and for the spouses and children of veterans who died of service-connected disability; also known as VHA. |
| Closed Formulary | Tight restriction of medication use to the medications included in the formulary list; meds that are not listed as preapproved drugs per the health plan provider or pharmacy benefits manager are not reimbursed except under certain circumstances & docu. |
| Co-payment | The portion of the prescription bill that the patient is responsible for paying. |
| Deductible | The amount paid by a policyholder out of pocket before the insurance company pays a claim. |
| Direct manufacturer ordering | Pharmacies may join a group purchasing organization and contract directly with the manufacturer to obtain better pricing. |
| Drug Utilization Evaluation (DUE) or review (DUR) | An ongoing review by a pharmacist of the prescribing, dispensing, and use of medications, based on predetermined criteria, to decide whether changes need to be made in a patient's drug therapy. |
| Formulary | A list of pre-approved medications that are covered under a prescription plan or within an institution. |
| Health Insurance Portability & Accountability Act (HIPAA) | Federal guidelines for the protection of a patient's personal health info. |
| Health Maintenance Organization (HMO) | An insurance plan that allows coverage for in-network only physicians and services and uses the primary care physician as the "gatekeeper" for the patient's health care; patients often have copays to defray the costs of medical care & prescription drugs. |
| Inventory | The amount of product a pharmacy has for sale. |
| Just-in-time ordering | A system that orders a Product- just before its used. |
| Medicaid | A gov-managed insurance program that provides health care services to low-income children, elderly, blind, and those with disabilities. |
| Medicare | A gov-managed insurance program composed of several coverage plans; funded by both federal and state entities, must meet specific requirements to be eligible. Must be 65+ years, have long term disabilities, or have end-stage renal disease. |
| Medicare Modernization Act (MMA) | The enactment of prescription drug coverage provided for individuals covered under Medicare. |
| Medigap plan | Supplemental insurance provided through private insurance companies to help cover costs not reimbursed by the Medicare plan, such as coinsurance, copays, and deductibles. |
| National Drug Code (NDC) | A 10- digit # given to all drugs for identification purposes; in health and drug databases, the NDC is represented as an 11- digit #, in which placeholders 0's are inserted in the proper order. |
| National Provider Identifier (NPI) | A # assigned to any health care provider that is used for the purpose of standardizing health data transmissions. |
| Open formulary | A formulary list that is essentially unrestricted in the types of drug choices offered or that can be prescribed and reimbursed under the health provider plan or pharmacy benefits plan. |
| Patient profile | A document listing necessary patient personal and health info, including comprehensive info on the meds the patient is taking, disease states, and any food or drug allergies the person might have. |
| Periodic automatic replenishment (PAR) | The PAR of stock levels to a certain number of allowed units. |
| Pharmacy & therapeutics committee (P&T Committee) | Medical staff composed of physicians, pharmacists, pharmacy techs, nurses, & dieticians who provide necessary info & advice to to institution or insurer on whether a drug should be added to a formulary. |
| Point of Sale (POS) | A system that allows inventory to be tracked as it is used. |
| Preferred provider organization (PPO) | An insurance plan in which patients choose a provider from a specified list, resulting in reduced costs for medical services. |
| Prime vendor | A large distributor of meds & retail products that contracts with the pharmacy to deliver the bulk of their meds in exchange for lower prices. EX: McKesson, Cardinal Health, & AmerisourceBergen. |
| Prior authorization | Insurance-required approval for a restricted, nonformulary, or no covered med before a prescription med can be filled. |
| Safety Data Sheets (SDS's) | Info sheets supplied to the pharmacy from the manufacturer of chemical products; the SDS lists the hazards of the product and procedures to follow if a person is exposed to that product. |
| Trade, Brand, or proprietary drug name | The name a company assigns for marketing and identification purposes to a commercial drug product; most brand names are trademarked & belong to originator products; the named products are often protected for a time by patients. |
| Treatment authorization request (TAR) | The process used by Medicare & Medicaid for authorization of assistive tech devices costing more than $100; durable medical equipment also require a TAR; similar to a pre-authorization form. |
| TRICARE | A health benefit program for active duty & retired personnel in all seven uniformed services; it also covers dependents of military personnel who were killed while on active duty. |
| Wholesalers | Companies that stock a variety of drug manufactures' meds & normally have a "just-in-time" turnaround for ordered drugs; means drugs ordered today arrive next day. |
| Workers' Compensation | Gov-required & gov-enforced medical coverage for workers injured on the job, paid for by the employer; the programs are managed by each state in accordance with the state's workers' Compensation laws. |
| Capitation | Method of payment in which the doctor receives a fixed amount for each member patient regardless of how many times the patient visits the physician. |
| Medicare Part A | Helps cover inpatient care in hospitals, skilled nursing facilities, critical care hospitals, hospice, & some home health care; patients who are eligible for Social Security benefits are automatically enrolled. |
| Medicare Part B | Helps pay for physicians' services, outpatient care, durable medical equipment (DME), and even physical & occupational therapists when deemed medically necessary; coverage is optional, most ppl pay a monthly premium. |
| Medicare Part C | Allows participants in Medicare Parts A & B to obtain additional insurance through private HMOs or PPOs. |
| Medicare Part D | Provides people who are eligible for Medicare a voluntary prescription drug plan. |
| Class 1 recall | Recalls for drugs that may pose a serious threat to users' health or even death. |
| Class 2 Recall | Recalls for drugs that may cause a temporary health problem and have a low risk of creating a serious problem. |
| Class 3 Recall | Recalls for drugs that violate FDA regulations concerning container defects or have a strange taste or color. |
| Yellow waste container | Chemotherapy waste. |
| Black waste container | Hazardous drug waste including nitroglycerin. |
| Purple waste container | Pharmaceutical waste including live vaccines. |
| Blue & White waste container | Non-hazardous intravenous agents waste. |
| Temp requirements for freezer | -20 to -10C |
| Temp requirements for refridgerator | 2 to 8C |
| Temp requirements for room temp | 23C+ |
| DAW code 0 | Physician authorizes a therapeutic alternative and the pharmacy can dispense the generic drug to a patient. If generic isnt available, the trade name product must be given. |
| DAW code 1 | Used by a physician to indicate that the trade or brand name medication is in some way medically necessary for the successful treatment of the patient. |
| DAW code 2 | Physician has approved the generic substitution of the medication prescribed; however, the patient has insisted on receiving the brand name medication. |
| Third-party billing | Refers to the portion of payment reimbursed by insurance companies.3 entities responsible for payment include patient, pharmacy, and insurance company. |
| Drug Topics Red Book | Determines the price of a medication based on the listed price. |
| Limitation of plan exceeded | Patient who has exhausted his or her pharmacy benefits for the specified time period or quantity limitation on a drug. |
| Fast mover | Drugs kept in a separate area from the normal stock because of the high volume of use. Must be ordered often and in large quantities. |
| Slow mover | Drugs prescribed regularly but are not commonly prescribed. Must be checked before ordering and periodically to ensure drugs are not close to expiring. |
| Special orders | Drugs typically used by only a few patients. Usually ordered at the time of use. |
Created by:
Yari06
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