Pharmacy Technician Quiz – Financial & Billing Topics

A deductible is a set amount that the patient must pay out of pocket before the insurance company will start covering additional expenses. It is a predetermined amount that the patient is responsible for paying for each benefit period. Once the deductible is met, the insurance company will then begin covering a portion or all of the additional expenses. Deductibles are commonly found in insurance plans, including Medicare, and help to share the cost of healthcare between the patient and the insurer.

HMOs, POS, and PPOs are examples of managed care programs. Managed care programs are a type of healthcare delivery system that aims to control costs and improve quality by coordinating and managing healthcare services. HMOs (Health Maintenance Organizations) require members to choose a primary care physician and obtain referrals for specialist care. POS (Point of Service) plans allow members to receive care both within and outside the network, but with higher out-of-pocket costs for out-of-network care. PPOs (Preferred Provider Organizations) offer more flexibility in choosing healthcare providers, but usually have higher premiums and deductibles. These programs help to manage and coordinate healthcare services for their members.

Worker's compensation is the correct answer because it refers to an employer compensation program for employees who are accidentally injured on the job. This program provides financial support and medical benefits to employees who sustain work-related injuries or illnesses. It is designed to cover medical expenses, lost wages, and rehabilitation costs for injured workers, ensuring that they are adequately compensated and supported during their recovery process.

A co-pay is the portion of the price of medication that the patient is required to pay. It is a fixed amount that the patient must pay out of pocket for each prescription or medical service. This is different from co-insurance, which is a percentage of the cost that the patient is responsible for. The CMS-1500 form is a standard claim form used by healthcare providers to bill Medicare and Medicaid for services provided, while the CMS-10114 form is used for reporting home health services.

A dual co-pay refers to a system where there are two different prices for medications based on whether they are generic or brand-name. This means that individuals will have to pay one price for generic medications and a different price for brand medications. This system is commonly used by insurance plans to incentivize individuals to choose generic medications over brand-name ones, as they are usually cheaper. The term "dual" in dual co-pay signifies the existence of two separate prices for different types of medications.

Medication Therapy Management Services (MTMS) is the correct answer because it refers to a service provided to Medicare beneficiaries who are enrolled in Medicare Part D and who are taking multiple medications or have certain diseases. MTMS involves a comprehensive review of the patient's medications by a healthcare professional, who then provides education and counseling to optimize medication use and improve health outcomes. This service aims to ensure that patients are taking their medications correctly, avoiding potential drug interactions, and managing any side effects or complications.

A co-pay refers to the portion of the price of medication that a patient is required to pay. It is a fixed amount that is typically paid at the time of service or purchase of the medication. Co-insurance, on the other hand, refers to the percentage of the medication cost that the patient is responsible for paying. Maximum allowable cost is the maximum price that an insurance company will cover for a particular medication, and usual and customary price refers to the average price charged for a medication in a specific geographic area.

When a technician receives a rejected claim with the reason "invalid person code," it is likely because the person code entered does not match the birth date and/or sex in the insurer's computer. This could be due to a data entry error or incorrect information provided by the patient. It is important to verify and correct the person code to ensure accurate processing of the claim.

If a third party plan has a dual co-pay, the patient usually pays less for generic drugs compared to brand name drugs. This means that the cost of generic drugs is lower for the patient when compared to brand name drugs.

The correct answer is cms-10114 form. The cms-10114 form is the standard form used by health care providers to apply for a National Provider Identifier (NPI). The NPI is a unique identification number assigned to health care providers by the Centers for Medicare and Medicaid Services (CMS). This form allows providers to submit their information and apply for an NPI, which is necessary for billing and other administrative purposes in the healthcare industry.

Prescription drug benefit cards are the correct answer because they specifically refer to cards that contain third party billing information for prescription drug purchases. These cards are typically provided by prescription drug plans (PDPS) and are used to access prescription drug benefits. Other options such as universal claim forms and worker's compensation do not directly relate to third party billing information for prescription drug purchases.

A drug formulary is a list of medications that are covered by a third party program. This means that the program will provide coverage or reimbursement for the medications listed in the formulary. It is a helpful tool for patients and healthcare providers to determine which medications are covered by their insurance or benefit program, ensuring that they have access to the medications they need.

Medicaid is a federal-state program that provides health care for individuals with limited income and resources. It is administered by states, allowing them to determine eligibility criteria and the range of services covered. Medicaid aims to assist the needy by offering comprehensive health coverage, including doctor visits, hospital stays, prescription drugs, and more. Unlike Medicare, which primarily serves older adults and individuals with disabilities, Medicaid targets low-income individuals and families, helping them access necessary medical services and improve their overall health outcomes.

Closed formulary programs like Medicaid have a list of approved drugs that they cover. However, there may be cases where a patient needs a medication that is not on the formulary. In such situations, the program may provide coverage for these non-formulary drugs through a process called prior authorization. This process requires the patient's healthcare provider to submit a request explaining the medical necessity of the non-formulary drug. The program then reviews the request and decides whether to approve or deny coverage for the medication.

In online claim processing, weight is generally not required information. Birth date is necessary to verify the age of the claimant, sex is needed for identification purposes, and the group number is essential for determining the specific insurance plan. However, weight is not typically relevant to the claim processing and is therefore not required.

Online adjudication refers to the process of electronically verifying and processing insurance claims in real-time. In the context of prescription coverage, it involves the communication between the pharmacy computer and a third-party computer, such as an insurance provider or a pharmacy benefit manager, to determine the coverage and reimbursement for a particular medication. This automated process helps streamline and expedite the prescription filling process, ensuring accurate and efficient resolution of prescription coverage.

The maximum allowable cost (MAC) is the highest price per tablet or dispensing unit that an insurer or pharmacy benefit manager (PBM) will reimburse for a specific product. This means that the insurer or PBM will not pay more than the MAC for that particular medication. The MAC helps to control costs and ensure that the insurer or PBM is not overpaying for medications. It is a way to negotiate lower prices with manufacturers and pharmacies, ultimately saving money for both the insurer and the patient.

When a technician receives a rejected claim stating "NDC Not covered," it likely means that the insurance plan has a closed formulary. A closed formulary is a list of medications that are covered by the insurance plan, and any medication not included in this list will be rejected. Therefore, if the claim is rejected with this reason, it indicates that the specific medication requested is not covered by the insurance plan's formulary.

When a technician receives a rejected claim stating "unable to connect," it suggests that the connection with the insurer's computer is temporarily unavailable due to computer problems. This means that there is an issue with the communication between the technician's system and the insurer's computer system, which is causing the claim to be rejected. It is not related to incorrect patient information, expired coverage, or a closed formulary.

HMO's, or Health Maintenance Organizations, are a type of healthcare plan where a network of providers is established. The costs of medical services and treatments are covered only when received from providers within this network. If a person seeks healthcare services outside of the network, they may not be covered or may have to pay higher out-of-pocket costs. HMO's aim to control healthcare costs by limiting choices and promoting preventive care.

Medicaid is a federal-state program that is administered by the states and provides health care for individuals who are considered needy. It is designed to assist low-income individuals and families in accessing necessary medical services and covers a wide range of medical expenses. Unlike Medicare, which is a federal program primarily for individuals aged 65 and older, Medicaid is available to individuals of all ages who meet the eligibility criteria set by their state. Therefore, Medicaid is the correct answer in this context.

Patient assistance programs are programs sponsored by manufacturers that provide prescription drugs to individuals who are unable to afford them. These programs help needy patients by offering them access to medications at reduced or no cost. They are designed to assist individuals who do not have insurance or whose insurance does not cover the cost of their medications. Patient assistance programs play a crucial role in ensuring that individuals with limited financial resources can still receive the necessary medications to manage their health conditions.

The correct answer is 99605, 99606, and 99607. These are the CPT codes used for billing Medication Therapy Management Services provided by pharmacists. CPT codes are used in the healthcare industry to describe and report medical, surgical, and diagnostic services. In this case, these specific codes are used to accurately bill for the services provided by pharmacists during medication therapy management.

Pharmacy benefit managers are companies that administer drug benefit programs. They work as intermediaries between insurance companies, pharmacies, and patients to manage prescription drug benefits, including negotiating prices with drug manufacturers, processing claims, and developing formularies. They play a crucial role in controlling costs, ensuring access to medications, and promoting safe and effective drug use.

A third party refers to an entity other than the patient or the pharmacy that covers a portion or the entire cost of the medication. This could include insurance companies, government programs, or employers who provide healthcare benefits to their employees. These third parties help reduce the financial burden on the patient by sharing the cost of the medication.

The CMS-1500 form is a standardized form used by healthcare providers to bill for services provided to patients. It is used for submitting claims to Medicare, Medicaid, and other insurance companies. This form is used to document the details of the services provided, including the diagnosis, procedures performed, and charges. It is an important tool for healthcare providers to ensure accurate and timely reimbursement for their services.

A formulary is a list of medications that are covered by a third party plan, such as an insurance company or a pharmacy benefit manager. It serves as a guide for healthcare providers and patients to understand which medications are covered and at what cost. A formulary can be open, meaning it includes a wide range of medications, or closed, meaning it only includes specific medications. Therefore, the correct answer is "formulary".

U&C or UCR stands for "usual and customary" or "usual, customary, and reasonable" price. It refers to the maximum amount of payment that an insurer determines to be the standard price for a given prescription. This means that the insurer will only cover up to this amount, and any costs exceeding it will be the responsibility of the patient.

Prescription drug plans (PDPs) are third party programs specifically designed for Medicare Part D, which provides coverage for prescription drugs. PDPs are offered by private insurance companies and approved by Medicare. They help individuals with their prescription drug costs by offering a variety of coverage options and formularies. PDPs allow beneficiaries to choose from a range of plans that best meet their medication needs and budget. Therefore, the answer "prescription drug plans (PDPs)" accurately describes the third party programs available for Medicare Part D.

"Tier" refers to a classification system used by third-party plans to categorize medications based on their cost and coverage level. Medications are typically classified into different tiers, with each tier having a different copayment or coinsurance amount. Higher-tier medications usually have a higher cost-sharing amount compared to lower-tier medications. Therefore, the correct answer refers to one of the categories of medications covered by a third-party plan.

Co-insurance is an agreement for cost-sharing between the insurer and the insured. It means that both parties will share the costs of medical expenses after the deductible has been met. The insured will pay a percentage of the costs, while the insurer will cover the remaining percentage. This helps to distribute the financial burden between the two parties and ensures that both have a stake in the cost of healthcare services.

The correct answer is 1 because when a physician writes "DAW" (Dispense as Written) on a prescription, it indicates that the patient should receive the exact brand-name medication that was prescribed, rather than a generic substitute. Therefore, the appropriate DAW indicator for online adjudication would be necessary to ensure that the patient receives the correct medication as prescribed by the physician.

Co-insurance refers to a cost-sharing agreement between the insurer and the insured. It means that both parties will share the cost of covered healthcare services after the deductible has been met. For example, if the insurance policy has a co-insurance of 80/20, the insurer will pay 80% of the covered expenses, and the insured will pay the remaining 20%. This arrangement helps to distribute the financial burden between the insurer and the insured, ensuring that both parties contribute to the cost of healthcare services.

Pharmacy benefit managers (PBMs) are companies that administer drug benefit programs. They work with insurance companies, employers, and other healthcare organizations to manage and negotiate prescription drug benefits on behalf of their clients. PBMs are responsible for developing and maintaining formularies, negotiating drug prices with pharmaceutical manufacturers, processing and paying prescription claims, and providing clinical support and pharmacy network management. They play a crucial role in controlling healthcare costs and ensuring access to affordable medications for patients.

The correct answer is "telephone the insurance plan's pharmacy help desk." When there is a question on insurance coverage for an online claim, the pharmacy technician can contact the insurance plan's pharmacy help desk for assistance. This is the appropriate course of action as the help desk can provide guidance and clarification regarding the insurance coverage for the claim. Referring the problem to the pharmacist may not be necessary in this case, as the insurance help desk is specifically trained to handle insurance-related queries. Therefore, the correct answer is to telephone the insurance plan's pharmacy help desk.

A PPO (Preferred Provider Organization) is a network of healthcare providers where costs outside the network may be partially reimbursed and the patient's primary care physician does not need to be a member. This means that individuals with a PPO insurance plan have the flexibility to choose any healthcare provider, even if they are not part of the network, and still receive some reimbursement for the costs. This is different from an HMO (Health Maintenance Organization) where individuals are required to choose a primary care physician within the network and typically need a referral to see a specialist. Medicaid and Medicare are government-funded healthcare programs, but they do not specifically match the given description.

Dual co-pays refer to the type of plans where the patient is required to pay different amounts depending on whether a generic or brand name medication is dispensed. This means that if a generic medication is dispensed, the patient will pay a lower co-pay, while if a brand name medication is dispensed, the patient will pay a higher co-pay. This system allows for cost differentiation based on the type of medication being prescribed.

Patient assistance programs are programs offered by pharmaceutical manufacturers to help patients who cannot afford their medications. These programs provide financial assistance or free medications to eligible patients. HMOs, pharmacies, and physicians may play a role in the distribution or administration of these programs, but they are not the ones offering the programs themselves. Therefore, the correct answer is pharmaceutical manufacturers.

The correct answer is cms-1500. The CMS-1500 form is a standard form used by healthcare providers to bill for services. It is recognized by the Centers for Medicare and Medicaid Services (CMS) and is used for submitting claims for reimbursement from insurance companies. This form includes important information such as patient demographics, diagnosis codes, procedure codes, and billing information. It is widely used in the United States for both private and government insurance programs.

A Preferred Provider Organization (PPO) is a type of managed care program that allows individuals to visit any healthcare provider they choose, without requiring a referral from a primary care physician. Unlike Health Maintenance Organizations (HMOs) and Medicaid, PPOs do not typically require substitution, which means that patients can receive care from out-of-network providers at a higher cost. Medicare, on the other hand, is a federal health insurance program for individuals aged 65 and older, which may require substitution in certain cases. Therefore, PPO is the least likely to require substitution among the given options.

PPOs, or Preferred Provider Organizations, are a type of health insurance plan that allows policyholders to choose their healthcare providers from a network of preferred providers. These providers have agreed to provide services at a discounted rate to PPO members. PPOs are widely accepted by many insurers because they offer flexibility and choice to policyholders while still providing cost savings through the network of preferred providers.

Pharmacies do not receive payment from third parties equal to any of the mentioned options. The payment received by pharmacies from third parties is usually based on negotiated contracts and agreements. It may include factors such as the pharmacy's reimbursement rate, the patient's insurance coverage, and any applicable co-pays or deductibles. Therefore, none of the options provided accurately describe the payment pharmacies receive from third parties.

Online adjudication is the correct answer because it is a process in which health care providers submit claims electronically to insurance companies for reimbursement. This process is commonly used for billing Medicare and Medicaid, as well as other insurance providers. The code assigned is likely a unique identifier for the health care provider, which is necessary for online adjudication. Therefore, online adjudication is the correct answer as it aligns with the context provided in the question.

A Point of Service (POS) plan is a type of health insurance plan that allows patients to choose healthcare providers both inside and outside of a designated network. The plan typically offers partial reimbursement for costs incurred outside the network. Unlike other plans, such as Preferred Provider Organizations (PPOs) or Health Maintenance Organizations (HMOs), a POS plan does not require the patient's primary care physician to be a member of the network. Therefore, the given answer "POSs" correctly describes the 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 PPO (Preferred Provider Organization) is a network of healthcare providers where costs are covered inside the network, but not outside of it. This means that if a person with a PPO insurance plan seeks medical services from a provider within the network, the insurance will cover a significant portion of the costs. However, if they choose to go outside of the network to receive care, the insurance coverage may be limited or not cover the costs at all.