chapter7
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| audit | a challenge on a reimbursement from a PBM or insurance provider on a prescription claim that has been previously processed
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| average wholesale price (AWP) | the average price that wholesalers charge the pharmacy for a drug
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| certificate of medical necessity | form to be completed and signed by the prescriber for Medicare Part B insurance payment for diabetic supplies
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| charge-back | a rejection of a prescription claim by a PBM or an insurance provider that must be investigated and resolved
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| co-insurance | a percentage-based insurance plan in which the patient must pay a certain percentage of the prescription price
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| computer | an electronic device for inputting, storing, processing, and/or outputting information
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| coordination of benefits (COB) | online billing of both a primary and a secondary insurer
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| co-payment (co-pay) | the amount that the patient is to pay for each prescription as determined by insurance
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| credit card | a method of online payment that is a type of loan, either paid totally at the end of the month or partially with a finance charge added
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| database management system (DBMS) | application that allows one to enter, retrieve, and query records
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| days' supply | the duration of time (number of days) a dispensed medication will last a patient; required on drug claims submitted for insurance billing
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| debit card | a method of online cash payment that instantly deducts the cost of the purchase from the customer's bank account
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| deductible | an amount that must be paid by the insured before the insurance company considers paying its portion of a medical or drug cost
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| dietary supplement | a category of nonprescription drugs that includes vitamins, minerals, and herbals that are not directly regulated by the FDA like OTC drugs
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| discount | a reduced price
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| donut hole | insurance coverage gap in Medicare Part D programs by which the patient must pay a higher portion of the cost of the medication
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| dual co-pay | insurance coverage in which a patient pays one co-pay for brand name drugs and a lower co-pay for generic drugs
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| dumb terminal | a computer device that contains a keyboard and a monitor but does not contain its own storage and processing capabilities
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| durable medical equipment (DME) | medical equipment such as hospital beds, wheelchairs, canes, or crutches that may be covered under Medicare Part B insurance
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| Flex card | a medical and prescription insurance credit card
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| gross profit | the difference between the purchase price and the selling price; also called markup
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| health insurance | coverage of incurred medical costs such as physician visits, laboratory costs, and hospitalization
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| inventory | the entire stock of products on hand for sale at a given time
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| inventory turnover rate | the amount of time the average drug inventory will be replaced during a 12-month period; most pharmacies replace inventory every two to four weeks
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| inventory value | the total value of the entire stock of products on hand for sale on a given day
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| just-in-time (JIT) purchasing | frequent purchasing in quantities that just meet supply needs until the next ordering time
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| markup | the difference between the purchase price and the selling price; also called gross profit
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| Medicaid | a state government health insurance program for low-income and disabled citizens
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| Medicare Part D | a voluntary insurance program that provides partial coverage of prescriptions primarily for patients who are eligible for Medicare
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| nondurable medical supplies | consumable, disposable items that can only be used by one patient for a specific purpose
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| online adjudication | real-time insurance claims processing via wireless telecommunications
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| out of stock (OOS) | a situation in which the pharmacy does not have the prescribed drug in inventory
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| over-the-counter (OTC) drug | a medication that the FDA has approved for sale without a prescription; another name for nonprescription drug
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| partial fill | a situation in which the pharmacy cannot completely fill the prescribed quantity written on the prescription
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| perpetual inventory record | a record that accounts for each unit of Schedule II drug dispensed or received
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| prescription benefits manager (PBM) | a company that administers drug benefits from many insurance companies
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| posting | the process of reconciling the invoice and updating inventory at time of receipt
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| preferred drug list | a formulary provided by an insurance company that indicates preferred prescription generic and brand name drugs and their corresponding co-pays
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| prime vendor purchasing | an agreement made by a pharmacy for a specified percentage or dollar volume of purchases
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| prior authorization (PA) | approval for coverage of a high-cost medication or a medication not on the insurer's approved formulary
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| private insurance | coverage for medical or prescription costs provided by an employer or purchased by an individual
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| profit | the amount of revenue received that exceeds the expense of the sold product, services, and overhead
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| purchasing | the ordering of products for use or sale by the pharmacy
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| receipt | a printout that is a proof of purchase
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| receiving | a series of procedures for accepting the delivery of products to the pharmacy from a wholesaler or centralized warehouse
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| remote computer | a minicomputer or a mainframe that stores and processes data sent from a dumb terminal
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| Schedule V drug | a medication with a low potential for abuse and a limited potential for creating physical or psychological dependence; available in most states without a prescription
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| sharps | any needle, lancet, scalpel blade, or other medical equipment that could cause a cut or puncture
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| smart terminal | a computer that contains its own storage and processing capabilities
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| smurfing | a practice that occurs when a patient is paid cash by an individual to illegally purchase pseudoephedrine from more than one pharmacy
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| tiered co-pay | insurance coverage in which the patient has an escalating cost or co-pay, depending on whether the filled prescription is a generic drug, a preferred brand name drug, or a nonpreferred brand name drug
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| Tricare | a federal government health insurance program for active and retired military personnel and their dependents
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| uninsured | patients with no insurance who must pay out-of-pocket for medical and/or prescription costs
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| usual and customary charges | the total cost of dispensing a prescription to the general public; a pharmacy cannot bill government insurance programs more than the usual and customary charge
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| wholesaler purchasing | the ordering of drugs and supplies from a local vendor who delivers the product to the pharmacy on a daily basis
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| workers' compensation | insurance provided for a patient with a medical injury from a job-related accident; also called workers' comp
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