Ch. 14 - Financial Issues
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| 1st party | patient
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| 2nd party | health care provider: doctor, dentist, therapist, etc.
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| 3rd party | - health insurance companies can be private, public or managed organizations, and as well as pharmacy benefit manager (PBM).
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| co-insurance | an agreement for cost-sharing between the insurer and the insured.
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| co-pay | the portion of the price of medication that the patient is required to pay.
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| dual co-pay | co-pays that have two prices: one for generic, and one for brand medication.
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| maximum allowable cost (MAC) | the maximum price per tablet (or other dispensing unit) an insurer or PBM will pay for a given product.
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| online adjudication | the resolution of Rx coverage through the communication of the pharmacy computer with the third-party computer.
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| pharmacy benefit managers (PBM) | companies that administer drug benefit programs, represent mostly for the health insurance companies, process all patients' Rx bills that is sent by the pharmacies and make determinations of which are rejected or accepted.
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| Usual and Customary (U & C) or Usual, Customary and Reasonable (URC) | the maximum amount of payment for a given Rx, determined by the insurer to be a usual and customary (and reasonable) price.
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| deductible | a set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses.
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| formulary | a list of medications covered by third-party plans.
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| Rx drug benefit cards | cards that contain third-party billing information for Rx drug purchases.
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| tier | categories of medications that are covered by third-party plans.
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| HMO Health Maintenance Organizations | a network of providers for which costs ared covered inside but not outside of the network.
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| PPO Preferred Provider Organizations | 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.
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| POS Point-Of-Service Programs | a network of providers where the patient's primary care physician must be a member and costs outside the network may be partially reimbursed.
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| Medicaid | a federal-state program, administered by the states, providing health care for the needy.
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| Medicare | a federal program providing health care to people w/ certain disabilities or who are over age 65; it includes basic hospital insurance, voluntary medical insurance, and voluntary Rx drug insurance.
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| patient assistance programs | manufacturer sponsored Rx drug programs for the needy.
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| workers' compensation | an employer compensation program for employees accidentally injured on the job.
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| PDP Rx Drug Plans | third-party programs for Medicare Part D.
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| universal claim form (UCF) | a standard claim form accepted by many insurers.
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| CM-1500 form | the standard form used by health-care providers to bill for services, including disease state management services.
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| CMS-10114 form | the standard six-page form used by health care providers to apply for a national provider identifier (NPI).
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| National Provider Identifier (NPI) | the code assigned to recognized health-care providers; needed to bill MTM services
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| Medication Therapy Management (MTM) services | services provided to some Medicare beneficiaries who are enrolled in Medicare Part D and who are taking multiple medications or have certain diseases.
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| Current Procedural Terminology codes (CPT codes) | identifiers used for billing pharmacist provided MTM services
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