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Question:

The process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance policy:

A Coordination of Benefits

explanation

Coordination of benefits is important when a patient is covered by more than one insurance plan. Medicare is often one of the plans involved with COB.

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Which would not be considered a dependent of the employee who purchased the insurance?

child age 27 who does not have access to other health insurance

Children up to the age of 26 who do not have access to other health insurance can be considered dependents of the employee.

The codes used to bill different medical conditions are called ____.

ICD codes

While some people call the codes used to bill for medical conditions diagnosis codes, the official term is ICD codes. CPT codes are used to bill for procedures.

What is the markup for a drug that costs $9.99, has a dispensing cost of $2.75, and retails for $13.99?

$4.00

= $4.00. Markup is another term for gross profit. In this problem, the markup is equal to retail price (13.99) - Cost (9.99), which is $4.00.

Which Medicare program will reimburse an out- patient pharmacy for a patient’s prescription?

Medicare Part D

Medicare Part D provides for prescription medications, biologicals, insulin, vaccines, and select medical supplies. All medications are not covered under Medicare Part D.

Which of the following provides the Medicare prescription drug benefit?

Medicare Part D

Medicare Part D is a federal government program which subsidizes the costs of prescription drugs and drug insurance premiums for Medicare Recipients. This program was authorized by the Medicare Modernization Act of 2003.

A Health Maintenance Organization (HMO) requires a patient to use ____ and either recommends or requires the use of ____.

in-network pharmacies; generic drugs

Most HMOs require their members to utilize both in-network pharmacies and generic drugs, when available. If generic drugs are not required, they are usually highly recommended.

Which of the following pieces of information is not transmitted by online adjudication?

Pharmacy technician’s name

A pharmacist or pharmacy technician’s name is not transmitted during on-line adjudication. Information that is transmitted includes the date of service; patient information; prescriber information; quantity dispensed to include day’s supply; and medication information such as drug manufacturer, drug entity, and drug packaging.

The term used to describe the services provided by a pharmacy to patients in an assisted living facility or a nursing home is called ____.

long-term care

Long-term care pharmacies may provide services to patients in nursing homes, adult day care, home care, or assisted living. Some common services include IV therapy, medication dispensing, immunizations, and medication therapy management.

When do pharmacies not use ICD codes?

during drug recalls

Drug recalls do not use ICD codes. Drug recalls are done by lot numbers.

Which of the statements regarding the prescription drug benefits is true?

Drug benefits can include tiered copays and exclude certain drugs.

Prescription drug benefits are designed to control costs, and some of the controls in place are pricing tiers, covering and excluding medications, and drug classes and when refills can be processed.

What three components are needed to bill a pharmacy claim?

Member ID number, BIN, and PCN

In order to bill a patient’s insurance you must have the BIN and PCN to ensure proper routing of the claim as well as the member ID number to identify patient specific benefits. Even if the patient does not have their card, benefit information can still be obtained if they are able to provide these three key pieces of information.

A list of medications available for use within a health care system is called a:

Formulary

The primary function of a prescription formulary is to specify particular medications that are approved to be prescribed under a particular insurance policy. Formularies are developed by evaluating the safety, efficacy, and cost-effectiveness of various drugs. With a closed formulary the insurance policy won't pay for drugs that are not on the list. An open formulary allows drugs that are not on the list, but will generally charge a higher co-pay for those drugs.

Who is contracted by insurance companies to process the claims for the insurance company's members?

the PBM

A PBM or Pharmacy Benefits Manager handles all the claim process for an insurance company's members. PBMs will often use drug formularies, a list of approved drugs, to help control costs.

Which of the following groups does Medicaid not cover?

Single working individuals with above-average incomes

Medicaid does not cover individuals who have an above average income. Individuals covered under Medicaid include individuals earning less than a specified yearly income, individuals with disabilities, and children whose parents receive Medicaid.