Pharmacy Billing and Reimbursement

Things You Should About Pharmacy Billing And Reimbursement

It is vital to know the processes involved in administering medicine. Look at the pharmacy billing and reimbursement certificate program in this post.

January 1, 2022

Dispensing drugs directly from your practice is a worthwhile option to consider if you’re a physician with many offices. It can create an extra cash stream for your medical practice while also providing a welcome convenience for your patients.

Health care is a fast-paced industry, and working in dispensing may be challenging. It is vital to understand the processes involved in administering medications as part of your practice. It’s also a good idea to become familiar with any options that will make this process easier.

For this aspect of your practice, let’s look at the pharmacy billing and reimbursement certificate program in this post.

Besides, you can get more about Comprehensive PTCB Study Guide


PTCB Billing and Reimbursement credential holders have proven a deep awareness of third-party payers and pharmacy reimbursement mechanisms.  Individuals who get the certificate will show that they not only have the essential core knowledge but also that they are competent in leading this critical administrative job for a pharmacy, which assists patients in obtaining medicine.

Eligibility requirements

A candidate must have a current PTCB CPhT Certification and meet one of the following qualifying requirements:

  • Pathway 1: Finishing a PTCB-Recognized Billing and Reimbursement Education/Training Program and at least 6 months of work as a pharmacy technician.
  • Pathway 2: Have worked as a pharmacy technician for at least 12 months, with at least 50% of that time spent on pharmacy billing and reimbursement operations.


To receive the PTCB Billing and Reimbursement Certification, candidates must pass the Billing and Reimbursement Exam. The Billing and Reimbursement Exam consists of 70 multiple-choice questions on a computer. Expect to spend 1 hour and 30 minutes on the exam (5-minute tutorial, 1 hour and 20-minute exam, and 5-minute post-exam survey).

  • Exam content outline

As stated in the chart below, the Billing and Reimbursement Exam covers various subject topics arranged into four domains.

Programs and Eligibility (20%)

Programs and eligibility terminology

Third-party reimbursement types (e.g., PBM, medication assistance programs, self-pay)

Healthcare reimbursement systems in different settings (e.g., home health, long-term care, home infusion, health systems, community pharmacy, and ambulatory clinics)

Eligibility requirements for private and/or federally-funded insurance programs (e.g., Medicare, TRICARE, Medicaid)

Eligibility for patient assistance through available programs (e.g., a 340B eligible program)

Claims Processing and Adjudication (48%)

Pharmacy/medical claim processing terminology

Information needed to submit pharmacy/medical claims

General pharmacy claim submission process (e.g., data entry, verification, adjudication)

Third-party claim rejection troubleshooting and resolution

Methods for determining drug cost and sale prices (e.g., AWP, dispensing fees, gross and net profit, acquisition cost

Coordination of benefits or plan limitations to determine each party’s responsibility

Reimbursement policies for all plans being billed, regardless of contracted payers, HMOs, PPO, CMS, or commercial plans

Identification of formulary coverage or alternatives

340B terminology

Prior Authorization (20%)

Prior authorization terminology

Information needed to submit medical/pharmacy prior authorization (e.g., patient and prescriber information, drug, dose)

General process of prior authorization (e.g., from formulary alternatives to contacting the provider, then through payer to the patient)

Third-party prior authorization rejection trouble-shooting and resolution

Audits and Compliance (12%)

Audit and compliance terminology

Contract documentation for claims billed to specific insurance plans (e.g., ICD-10 codes, provider feedback and authorizations to change medications)

Federal laws/regulations regarding audits (e.g., mandated audits by CMS for all government-funded programs)

Accrediting bodies and surveys (e.g., URAC, TJC, CMS, DNV)

Exam passing score

Using industry best practices, a panel of subject-matter experts determined a passing score for the Billing and Reimbursement Exam. The modified-Angoff approach was utilized by the panel, as recommended by a psychometrician. Experts (panel members) examine individual test questions and estimate the proportion of trained pharmacy technicians who would be able to answer each question correctly using this technique. The passing score was calculated by averaging these estimations and looking for consistency. Scaled scores are used to report the passing score and candidate results. The Billing and Reimbursement Exam has a passing scaled score of 300. Based on the exam subject outline, potential scores range from 0 to 400.

7 things about pharmacy billing and reimbursement

Pharmacy Billing and Reimbursement
Pharmacy Billing and Reimbursement


1. Data workflow

It’s critical to understand pharmacy billing and how pharmacies manage revenue and costs if you want to maintain your dispensing program viable and expandable. You must ensure that the process is controlled and monitored from purchase to inventory, storage and dispensing, and finally invoicing and reimbursement to close the revenue cycle. To avoid time-consuming and costly errors, all data must be entered accurately from the start.

2. Procurement

Procurement is the process at which data transitions from bought quantities and pricing to storage units of measure (UoM) and inventory expenses. The majority of the time, data is input manually. To avoid mistakes, figures uploaded from the wholesale distributor to the pharmacy’s system are manually reviewed. This is done because data transfer might be a source of errors, which can lead to ineffective revenue cycle management.

3. The Charge master

A key component of the medicine revenue cycle is the charge master, often known as the pharmacy charge description master. It is a list of billable things to a patient or health insurance provider that serves as the beginning point for invoicing patients and payers.

Separately reimbursable drugs that are miscoded or omitted in the charge master might result in revenue loss, thus proper attention is required. Converting pharmaceutical quantities from bought to patient-administered amounts is the key. To prevent conflating dosage amounts necessary for patients with amounts purchased, they should only be declared billable at this point. A reliable billing service can help you prevent costly mistakes and save time when it comes to data transfer.

4. Linkages between Purchases & Billing

Ordering, administering, and processing drug reimbursements may all be handled differently in various hospitals. Pharmacies may be asked to reconcile the linkage between medication expenses and the charge master, potentially resulting in erroneous reimbursement. For your drug dispensing organization, having a system in place that simplifies the entire process might be a godsend.

Your patients will feel better at ease receiving their medicine from their doctor. It will not only save them a trip to the pharmacy, but it will also ensure that any questions they may have regarding their medicine will be fully answered. You can make this part of your practice efficient, profitable, and a selling point for your offices by following best pharmacy billing and reimbursement practices.

5. Coding

Coding is another important consideration to avoid costly mistakes. Drugs must be coded appropriately in HCPCS and represented correctly in the charge master. It is possible that the pharmacy will not be reimbursed if this is not done correctly.

6. Drug prices

Drug prices, like any other product, are subject to market forces. However, there are a few corridors through which medicine may be obtained at a lower cost. Hospitals, for example, may frequently purchase pharmaceuticals at higher rates than fixed-fee payers can. Generic options that are less expensive are frequently overlooked. You may gain economies of scale by having a system in place to do frequent price research and compare drug spending to reimbursement.

7. Rules & regulations & Compliances

In terms of legality and standards, the healthcare field, particularly anything involving drugs, is a volatile space. Failure to keep up with the ever-changing CMS drug-related requirements might result in your practice being labeled non-compliant and losing out on payment. To avoid this, pharmacies must adhere to the CPT (Current Procedural Terminology) codes provided to pharmacists who do Medication Therapy Management (MTM). On all claims, pharmacies must provide the NPI as well as the NPI of the prescriber.

We hope that all the information and knowledge about pharmacy billing and reimbursement provided in this article can help you when taking the PTCB® exam as well as working in the pharmacy.

If you want to get more information, visit our website and take our free PTCE practice test, or download it for your IOS or Android devices now!