pharmacy technician insurance specialist
job title that describes the vital job of getting paid for prescriptions, whether the setting is a large pharmacy practice where individuals specialize in various task or a small practice where the same individual may handle this role as well as others, s
medical insurance
individual who enters into an agreement with a health plan to receive medical insurance
health plan & insurance payers
organization that offers financial protection in case of illness or accidental injury
policyholder
Individual who enters into an agreement with a health plan to receive medical insurance
premium
fee paid monthly to a health plan by a person who buys medical insurance
benefits
payments made by a health plan for medical services
providers
hospital, physician, and other medical staff members and facilities that offer medical services
deductible
amount paid by a policyholder each year before benefits from a health plan will start
medically necessary
insurance term referring to appropriate medical treatment given under generally accepted standards of medical practice
pharmacy benefit
feature of a policy that provides coverage for selection of prescription medications
Prescription drug list (PDL) & formulary & preferred drug list
list containing the Food and Drug Administration (FDA) -approved brand-name and generic medications a plan covers
noncovered (excluded) services
services that a medical insurance policy does not pay for
maximum benefit limit
monetary amount after which a plan's benefits end
coinsurance
percentage of the fees owed by the policyholder
managed care
method of supervising medical care with the goal of ensuring that patients get needed services in the most appropriate, cost- effective setting
managed care organization (MCO)
plan that establishes links among provider, patient, and payer by combining the delivery of services with the financing and management of health care
copayment
small fixed fee paid by a patient for a drug
point of sale (POS)
drug plan benefits received at the time the pharmacy technician insurance specialist processes a person's prescriptions
billing cycle
ten-step work flow followed at a pharmacy to care for patient's financial matters
electronic prescribing (eRx)
use of software by a physician to transmit an order
pharmacy management (PM) system
system that stores, processes, transmits, and receives billing data
pharmacy claim
information transmitted to a payer that identifies the policyholder, the prescriber the pharmacy sending the claim, and the medications being supplied
EDI (electronic data interchange)
claims that are sent electronically between the pharmacy management system and the payer
adjudication
payer's processing of claim data to decide whether a drug is covered by the patient's plan and properly utilized
accounts receivable (AR)
remaining balance due after an initial payment had been made
remittance advice (RA) &explanation of benefits
Document that comes to a pharmacy showing the details for a claim
Medically Necessary
1. They match the patient's illness
2. They are not elective. They are required to treat a condition, rather than being elected to be done by the patient.
3. They are not experimental. The procedures or medications must be approved by the appropriate fede
Indemnity plans
cover the medical costs policyholders incur when they receive treatment for accidents and illnesses.
Government Programs
Medicare, Medicaid, TRICARE, CHAMPVA, Workers' compensation
Medicare
a federal health plan that covers most citizens aged sixty-five and over, people with disabilities, people with end-stage renal disease (ESRD), and dependent windows.
Medicaid
Low income people who cannot medical care are covered by Medicaid, which is cosponsored by the federal and state governments.
TRICARE
TRICARE covers expenses for dependents of active-duty members of the uniformed services and for retired military personnel.
CHAMPVA
The Civilian Health and Medical Program of the Department of Veteran Affairs is a program for veterans with permanent service related disabilities and their dependents.
Worker's compensation
People with job-related illnesses or injuries are covered under workers' compensation insurance through their employers.
The Pharmacy Practice Billing Cycle
1. Receipt of Prescription
2. Patient Interview
3. Filling of Prescription
4. Pharmacy Claim Transmittal
5. Payer Adjudication
6. Point-of-Scale Patient Payment
7. Calculation of Payer Claim Balance
8. Accounts Receivable Follow-Up
9. Payment Processing
1
Receipt of Prescription
The patient or caregiver personally phones in the prescription or presidents it at a face-to-face meeting.
The physician or physician representative phones in the prescription.
The physician or physician representative fax in the prescription.
In a small
Patient Interview
the patient or the caregiver is interviewed to determine whether the pateint is a returning or a new customer of the pharmacy and is covered by a prescription drug plan.
Filling of Prescription
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