Insurance Info & Adjudication

What is the purpose of a BIN (Bank Identification Number) on an insurance card?

A: A 6-digit code used to identify the third-party payer for pharmacy claims

Q: What does the PCN (Processor Control Number) do?

A: Refines claim processing and specifies how the claim should be handled.

Q: What does a Member ID number represent?

A: A unique identifier for each member of an insurance plan.

Q: What is the Person Code on an insurance card?

A: Differentiates individuals within the same family plan (e.g., 00 = primary).

Q: What does the RX Group Number indicate?

A: Specifies the pharmacy benefits category a patient is entitled to.

Q: What is the process of adjudication in pharmacy?

A: Electronic submission of a claim to insurance to determine coverage, patient responsibility, and pharmacy payment.

Q: What are pre-adjudication alerts?

A: Warnings before claim submission, such as missing information or incorrect NDC.

Q: What are post-adjudication alerts?

A: Notifications after processing, showing approval, rejection, or info like deductible and refill limits.

Q: What is third-party processing?

A: Coordination between pharmacy, patient, and insurance to determine payment allocation and copays.

Q: When is coordination of benefits needed?

A: When a patient has multiple insurance plans, ensuring claims are processed in the correct order.

Q: What is a formulary?

A: A list of medications covered by insurance; non-formulary drugs may require full cost or an alternative.

Q: What are examples of Durable Medical Equipment (DME)?

A: Wheelchairs, crutches, blood glucose monitors, etc.

Q: Why does DME often require special billing?

A: Many DME items need prior authorization from insurance.

Q: What are common reasons for insurance claim rejections?

A: Missing/incorrect info, prior authorization needed, or exceeding day supply.

Q: How should a pharmacy technician handle claim rejections?

A: Correct errors, resubmit the claim, and communicate with both patients and prescribers.