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Mod Week 3

Chp. 14 end of review

QuestionAnswer
Patient assistance programs Manufacturer sponsored prescription drug program for the needy.
Pharmacy benefit managers Companies that administer drug beneift programs.
POS A network of providers where the patient's primary care physician must be a memeber and costs outside the network may be partially reimbursed.
PPO A network of providers where costs outside the network may be partially reimbursed and the patient's primary care physician need not be a member.
Prescription drug benefit cards Cards that contain third party billing informtion for prescription drug purchases.
Tier Categories of medications that are covered by a third party plan.
U&C or UCR The maximum amount of payment for a given prescription, determined by the insurer to be as usual and customary (and reasonable) price.
Universal claim form A standard paper claim form accepted by many insurers.
Worker's compensation An employer compensation program for employees accidentally injured on the job.
Prescription Drug Plans (PDPs) Third party programs for Medicare Part D.
Companies that administer drug benefit programs are called? Pharmcay benefit managers
Another party, besides the patient or the pharmacy, that pays some or all of the cost of the medication is a (an)? Third party
An agreement for cost-sharing between tghe insurere and the unsured is called? Co-insurance
The portion of the price of the medication that the patient is required to pay is called the? Co-pay
Plans in which the patient pays a different amount depending on whether a generic or brand name medication is dispensed have? Dual co-pays
If a third pary plan has a dual co-pay, the patient usually pays_____for generic drugs compard to brand name drugs. Less
A (an)_____is a network of providers for which costs are covered inside, but not outside of the network. HMO
A (an)______is a network of providers where costs outside the network may be partially reimbursed and the patient's primary care physician need not be a member. PPO
Which type of managed care programis least likey to require generic substitution? HMO
`A drug formulary is? A lsit of medications that are covered by a third party program.
__________is a federal-state program, administerd by states, providing health care for the needy. Medicaid
Closed formulary programs, such as Mecicaid, may cover drugs that are not on the formulary through a process called? Prior authorization
Patient assistance programs are offerd by? Pharmaceutical manufacturers
Which of the following information is generally nto required in online claim processing? Weight
The DAW indicator that is appropriate for on line ajudication if a physician has hand-written on the prescrition is? One
When there is a question on insurance coverage for an online claim, the pharmacy technician can? Telephone the insurance plan's pharmacy help desk
When a technician receives a rejectd clain "NDC Not covered", this probably means? The insurance plan has a closed formulary
When a technicain receives a rejected claim "invalid person code", this probably means? The person code entered does not match the birth dat and/or sex in the insurer's computer.
When a technicain receives a rejected claim "Unable to connect", this probably means? The connection with the insureer's computer is temporarily unavailable due to computer problems.
A standard form used by healthcare providers to bill for services is? CMS-1500
The CPT Codes for biling Medication Therapy Management Services provided by pharmacists are? 99605,99606,99607
Created by: nettyg
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