What government entity runs Medicaid?

Which organization developed billing rejection codes for third-party prescriptions?

NCPDP

Third-party rejection codes were developed by the National Council for Prescription Drug Pro- grams (NCPDP). A bank identification number (BIN) is a six-digit number used to identify the company that will reimburse the pharmacy for the prescription being filled. Good manufacturing practices (GMPs) are principles that are followed in drug manufacturing and compounding to en- sure product quality. SCRIPT is the standards by which prescriptions are transferred to another pharmacy.

Patients with more than one third-party payer will utilize this process for the benefits of both plans to be used.

coordination of benefits

When patients have more than one plan, a coordination of benefits will need to occur. Both plans will communicate and decide which plan is the primary payer. Most pharmacies will not manage this, and patients will need to submit claims on their own to each insurance company.

The cost for a bottle of 100 test strips for a glucometer is $67.50. The overhead for the store is $3.50, and the store wants to make a net profit of $23.68. What should the selling price be?

$94.68

Answer = $94.68. Add the cost of the test strips ($67.50) to the overhead costs ($3.50) to obtain the total cost ($67.50 + $3.50 = $71.00). To calculate the selling price, add the total cost and net profit together to obtain the selling price: $71.00 + $23.68 = $94.68.

Which of the following is not an advantage of standardized prescription card format?

Increased calls to help desks

A standardized prescription card format does not result with increased calls to the help desk; it does the opposite because the number of calls will decrease. A standardized prescription card format will result in a speedier prescription claim process and fewer problems with claims submission and will allow for additional time to be able to counsel patients.

What is the gross profit for a drug that has an AWP of $59.99, has a dispensing cost of $3.75, and retails for $67.99?

$8.00

Answer = $8.00. Gross profit can be calculated by subtracting the cost, which in this case is the same as the average wholesale price (AWP) or from the retail price: $67.99 - $59.99 = $8.00.

The process in which a drug requires further review to determine if it is covered is called ____.

prior authorization

Some drugs require further review through a process called prior authorization. This process can take 24 to 48 hours for review.

What is a flexible spending account?

an account through a patient's employer where patients can use pre-tax dollars for medical expenses

Flexible spending accounts can be used by self-pay patients to help with covered medical expenses.

Which of the following should not be a factor in selecting medications for a formulary?

Drug cost

Although the drug’s cost does play an important role in developing a formulary, it should not be the basis of including it in the formulary. Medications should be obtained from a reputable drug source (manufacturer). The drug should be pure, safe, and effective for the condition being treated.

When a provider receives payment based on the condition he or she is treating, it is called ____.

the episode-of-care approach

In episode-of-care approach, the fee is not for each individual service provided but for the treatment of a specific condition.

Patients in a Preferred Provider Organization (PPO) can use ____.

in-network or out-of-network pharmacies

PPOs allow patients to use in-network or out-of-network pharmacies. However, patients will have a larger cost when they utilize out-of-network pharmacies.

Which of the following managed care programs are provided to individuals or families that are below an income level during a calendar year?

Medicaid

Medicaid is a federal program that provides medical services and prescriptions at a very low cost to individuals or families who are below a predetermined income level. Medicare is federal program for elderly and permanently disabled individuals with medical and prescription care at a reduced rate to subscribers. A health maintenance organization (HMO) and a preferred provider organization (PPO) are examples of two forms of managed care organizations.

What government entity runs Medicaid?

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