chapter 7 part 4
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| health insurance can cover | visits, lab costs, & hospitalization
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| many small employers don't have | insurance for employees
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| cost of private health insurance is | often prohibitive
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| medical & medicare offer | eligible applicants coverage
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| many insurance companies process claims by | rx benefits managers
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| prescription benefits manager is | PBM
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| techs should know that a deductable is the | insurance paid amount
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| co-payments are the | customer paid amounts
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| tiered co-pay is an escalating cost/co-pay for | generic rx's & (non)prefered brands
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| online adjudication uses electronic communcation to | process rx claims
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| 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
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| online adjudication is real time insurance claims processed by | wireless telecommunications
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| medicaid is operated by each state & subsidizes | healthcare for indigent & disabled citizens
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| state reimbursement to pharm]s is limited to | "usual & customary charges"
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| some communicate pharm]s don't process | medicaid coverage due to low reimbursement rates or other factors
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| medicaid is state gov'tal & is for | low-income & disabled citizens
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| tricare is a federal plan with health/drug coverage for | active/retired military members & their families
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| tricare has low co-pays & covers | 90 days worth of medical supplies
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| medicaid part d is voluntary; | patients may continue current drug coverage
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| medicaid pt. d is complex; there are many coverage choices but patients usually | save 25-30% on rx's
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| medicaid pt. d has a coverage gap or "donut hole" when | yearly drug costs are between $3000-5500
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| within the medicaid pt. d gap, patients must | pay 100% of costs
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| medicaid pt. d has a list of | lower cost preferred drugs
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| techs can help patients understand their | insurance coverage
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| workers comp. is temporary insurance & the drug coverage is limited to | needs for injury treatment
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| workers comp. is a | secondary insurer
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| techs sometimes must coordinate benefits between | customers primary & secondary insurance
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| pharm] software determine | resolution methods
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| techs should learn about insurance plans & their interface with | the pharm] software
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| a coordination of benefits is an online billing of | primary/secondary insurers
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| getting & entering insurance info is | challenging
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| any change in insurance must be | updated when entered
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| insurance info includes | patient id & code, rx plan provider, BIN no., processor control no., & group id
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| insurance claims may be denied if | day supply is miscalculated
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| pharm]s may directly bill | insurance plan
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| discount cards & coupons may | be used also
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| PA is when the prescriber or tech calls the | insurance company for drug coverage to justify use
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