3rd Party Prescription Processing

The rejection message from the third-party processor is standardized by

the National Council for Prescription Drug Programs (NCPDP)

Prior authorization rejection

The insurance requires additional information to determine if the medication will be covered. Send paperwork to the provider for completion through electronic programs like CoverMyMeds.

Insurance providers may only pay for approved drugs that is in their

formulary

High tier copayment

more expensive

Generic substitutions are usually considered what tier of copay?

1

Coordination of Benefits (COB)

A patient is covered by multiple insurance plans. Need to determine which plan is to be billed as the primary insurance and the extent that the other plans will contribute after the primary has been billed. COB prevents patients from submitting on claim to multiple insurance companies.

Medicaid in COB

Always the payer of last resort.