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pht 100

chapter 7 part 4

health insurance can cover visits, lab costs, & hospitalization
many small employers don't have insurance for employees
cost of private health insurance is often prohibitive
medical & medicare offer eligible applicants coverage
many insurance companies process claims by rx benefits managers
prescription benefits manager is PBM
techs should know that a deductable is the insurance paid amount
co-payments are the customer paid amounts
tiered co-pay is an escalating cost/co-pay for generic rx's & (non)prefered brands
online adjudication uses electronic communcation to process rx claims
when billing to a PBM, the pharm] right away finds out what to charge the patient, how much reimbursement for the pharm] is whether or not the cost is covered, or if deductible is met first
online adjudication is real time insurance claims processed by wireless telecommunications
medicaid is operated by each state & subsidizes healthcare for indigent & disabled citizens
state reimbursement to pharm]s is limited to "usual & customary charges"
some communicate pharm]s don't process medicaid coverage due to low reimbursement rates or other factors
medicaid is state gov'tal & is for low-income & disabled citizens
tricare is a federal plan with health/drug coverage for active/retired military members & their families
tricare has low co-pays & covers 90 days worth of medical supplies
medicaid part d is voluntary; patients may continue current drug coverage
medicaid pt. d is complex; there are many coverage choices but patients usually save 25-30% on rx's
medicaid pt. d has a coverage gap or "donut hole" when yearly drug costs are between $3000-5500
within the medicaid pt. d gap, patients must pay 100% of costs
medicaid pt. d has a list of lower cost preferred drugs
techs can help patients understand their insurance coverage
workers comp. is temporary insurance & the drug coverage is limited to needs for injury treatment
workers comp. is a secondary insurer
techs sometimes must coordinate benefits between customers primary & secondary insurance
pharm] software determine resolution methods
techs should learn about insurance plans & their interface with the pharm] software
a coordination of benefits is an online billing of primary/secondary insurers
getting & entering insurance info is challenging
any change in insurance must be updated when entered
insurance info includes patient id & code, rx plan provider, BIN no., processor control no., & group id
insurance claims may be denied if day supply is miscalculated
pharm]s may directly bill insurance plan
discount cards & coupons may be used also
PA is when the prescriber or tech calls the insurance company for drug coverage to justify use
Created by: wildap



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