Pharm Tech Chapter 14 (financial Issues)
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- Financial issues, - Third Party Programs, - Online Adjudication, - Rejected Claims, - Other Billing Procedures
- 1.The resolution of prescription coverage through the communication of the pharamacy computer with the third party computer
- A.
Online adjudication
- B.
Medicaide
- C.
Medicare
- D.
Co-pay
- 2.The portion of the price of medication that the patient is requried to pay
- A.
CMS-1500 form
- B.
CMS - 10114 form
- C.
Co-insurance
- D.
Co-pay
- 3.The maximum price per tablet (or tother dispensing unit) an insurer or PBM will pay for a given product
- A.
HMO's
- B.
Maximum allowable cost (MAC)
- C.
Dual co-pay
- D.
Co-insurance
- 4.A federal-state program, administered by the states, providing health care for the needy
- A.
Medicaid
- B.
Medicare
- C.
Midication therapy management services (MTMS)
- D.
None of the above
- 5.A cost-sharing agreement bettween the insurer and the insured
- A.
Co-insurance
- B.
Co-pay
- C.
Deductible
- D.
Dual co-pay
- 6.Co-pays that have two prices: one for generic and one for brand medications
- A.
Formulary
- B.
Dual co-pay
- C.
Co-pay
- D.
Co-insurance
- 7.A set amount that must be paid by the patient for each benefit period before the insurer will cover additional expenses
- A.
Current procedural terminology codes (CPT CODES)
- B.
Dual co-pay
- C.
Deductible
- D.
Medicare
- 8.A network of providers for which costs are covered inside but not outside of the network
- A.
HMO's
- B.
Medication Therapy Management Services ( MTMS )
- C.
National Provider Identifier (NPI)
- D.
Fromulary
- 9.A federal program providing health care to people with certain disabilities over age 65
- A.
Cms-1500 form
- B.
Cms-10114 form
- C.
Co-insurance
- D.
Co-pay
- 10.Service provided to some Medicare beneficiaries who are enrolled in Mediare Part D and who are taking multiple medicatons or have certain diseases
- A.
Medication Therapy Management Services (MTMS)
- B.
National Provider Identifier (NPI)
- C.
Online adjudication
- D.
Deductible
- 11.The code assigned recognized health care providers; needed to bill MTMS
- A.
Online adjuication
- B.
Medicare
- C.
Medicaid
- D.
None of the above
- 12.The standard from used by health care proviers to apply for a National Provider Identifier (NPO)
- A.
Cms-1500 form
- B.
Cms-10114 form
- C.
Co-pay
- D.
Co-insurance
- 13.A list of medications that are covered by a third party plan
- A.
Open formulary
- B.
Closed formulary
- C.
Formulary
- D.
None of the above
- 14.Companies that administer drug benefit programs
- A.
Pharmacy benefit managers
- B.
POSs
- C.
Prescription Drug Plans PDPs
- D.
Universal claim form
- 15.A standard paper claim from accepted by many insurers
- A.
PPOs
- B.
POSs
- C.
U&C or UCR
- D.
Tier
- 16.The maximum amount of payment for a given prescription, determined by the insurer to be usual and customary (and reasonable) price
- A.
U&C or UCR
- B.
POSs
- C.
PPOs
- D.
Tier
- 17.Manufacturer sponsored prescription drug programs for the needy
- A.
Pharmacy benefit mangers
- B.
Prescription drug benefit cards
- C.
Patient assistance programs
- D.
Universal claim from
- 18.Cards that contain third party billing information for prescription drug purchases
- A.
Prescription drug plans (pdps)
- B.
Prescription drug benefit cards
- C.
Universal claim form
- D.
Worker's compensation
- 19.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
- A.
POSs
- B.
Ppos
- C.
Pdps
- D.
None of the above
- 20.An employer compensation program for employees accidentally injured on the job
- A.
Worker's compensation
- B.
UNIVERSAL CLAIM FORM
- C.
TIER
- D.
All the above
- 21.Third party programs for Medicare Part D.
- A.
Prescription drug benefit cards
- B.
Prescription drug plans pdps
- C.
Ppos
- D.
Pos
- 22.Categories of medications that are covered by a third party plan
- A.
Tier
- B.
Pos
- C.
Pdps
- D.
Ppo
- 23.Companies that administer drug benefit programs are called
- A.
Pharmacy benefit managers
- B.
MACs
- C.
HMOs
- D.
Employers
- 24.Another party, besides the patient or the pharmacy, that pays some or all of the cost of the medication is a(an)
- A.
Third party
- B.
Co-insurance
- C.
MAC
- D.
UCR
- 25.AN AGREEMENT FOR COST-SHARING BETWEEN THE INSURER AND THE INSURED IS CALLEDD
- A.
MAC
- B.
Dual co-pay
- C.
Co-insurance
- D.
Co-pay
- 26.The portion of the price of the medication that the paitent is required to pay is called the?
- A.
Co-insurance
- B.
Co-pay
- C.
Maximum allowable cost
- D.
Usual and customary price
- 27.Pharmacies receive payment from theird parities equal to
- A.
The retail price of the drug
- B.
The manufacturer's cost
- C.
A wholesaler's price
- D.
None of the above
- 28.Plans in which the patien pays a different amount depending on whether a generic or brand name medication is dispensed have
- A.
Dual co-pays
- B.
MAC
- C.
Duplicate pricing
- D.
UCR
- 29.IF A THIRD PARY PALN HAS A DUAL CO-PAY, THE PATIENT USUALLY PAYS ____ FOR GENERIC DRUGS COMPARED TO BRAND NAME DRUGS
- A.
The same amount
- B.
Less
- C.
More
- D.
None of the above
- 30.HMOs, POS, and PPOs are examples of
- A.
Co-insurance
- B.
Managed care programs
- C.
MAC
- D.
Co-pays
- 31.A(an) ______ is a network of providers for which costs are covered inside, but not outside of the network
- A.
POS
- B.
HMO
- C.
MAC
- D.
PPO
- 32.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.
- A.
Medicare
- B.
Ppo
- C.
Medicaid
- D.
Hmo
- 33.Which type of managed care program is least likely to require substitution?
- A.
Medicare
- B.
Ppo
- C.
Medicaid
- D.
Hmo
- 34.A drug formulary is
- A.
A list of medications that are covered by a third party program
- B.
An official compendium of the FDA
- C.
A listing of the ingredients in a prescription
- D.
The price of a prescription under third party program
- 35._____ is a federal-state program, administered by states, providing health care for the needy
- A.
Medicaid
- B.
Hmo
- C.
Medicare
- D.
Ppo
- 36.Closed formulary programs, such as medicaid, may cover drugs that are not on the formulary through a process called
- A.
Dual co-pay
- B.
Co-insurance
- C.
Pos
- D.
Prior authorization
- 37.PATIENT ASSISTANCE PROGRAMS ARE OFFERED BY
- A.
Hmo
- B.
Pharmacies
- C.
Physicians
- D.
Pharmaceutical manufacturers
- 38.Which of the following information is generally not required in online claim processing
- A.
Birth date
- B.
Weight
- C.
Sex
- D.
Group number
- 39.The DAW indicator that is appropriate for online adjudication if a physician has hand written DAW on the prescription
- A.
4
- B.
2
- C.
1
- D.
3
- 40.When there is a question on insurance coverage for an online claim, the pharmacy technician can
- A.
Telephone the insurance plan's pharmacy help desk
- B.
Immediately refer the problem to the pharmacist
- C.
All the above
- D.
None of the above
- 41.When a technician receives a rejected claim "NDC Not covered", this probably means?
- A.
The insurance plan has a closed formulary
- B.
The insurance plan has an open formulary
- C.
The birth date submitted does not match the birth date in the insurer's computer
- D.
The patient has mail order
- 42.When a technician receives a rejected claim "invalid person code, " this probably means
- A.
The patient is on medicare
- B.
The patient has a mail order program
- C.
The person code entered does not match the birth date and/or sex in the insurer's computer
- D.
The patient is on medicaid
- 43.When a techician receives a rejected claim "unable to Connect, " this probably means
- A.
The insurer has an incorrect birth date for the patient
- B.
The patient's coverage has expired
- C.
The connection with the insurer's computer is temporarily unavailable due to computer problems
- D.
The insurer has a closed formulary
- 44.A standard form used by healthcare providers to bill for services is
- A.
A universal claim form (UCF)
- B.
A pdf
- C.
An NDC
- D.
Cms-1500
- 45.The CPT Codes for billing Medication Therapy Management Services provided by pharmacists are
- A.
ICD-9
- B.
MAC
- C.
PPO
- D.
99605,99606, and 99607
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