Pharmacy Tech Ch.8 Keyterms

Audit- A challenge on a reimbursement from a PBM or insurance provider on a prescription claim that has been previously processed.

AWP (average wholesale price)- The average price that wholesalers charge the pharmacy for a drug, serving as the benchmark price to estimate reimbursement rates and retail price without insurance.

Benefit- The provision of health and drug insurance coverage by an employer.

catastrophic insurance- A plan that is aimed at protecting oneself from the high costs of a severe accident or unexpected, debilitating illness or disease; it has low monthly premium payments in exchange for a very high deductible (i.e. $5,000-$10,000) and is also referred to as a catastrophic coverage.

charge back- A rejection of a prior prescription claim by a PBM or an insurance provider that must be investigated and resolved.

cobra insurance- Insurance policy when a former employer is required to keep a former employee on the employee insurance plan at full premium cost for 18 to 36 months; the ACA guarantees such patients cannot lose coverage with job changes.

Coinsurance- a percentage-based insurance plan in which the patient must pay a certain percentage of the prescription price; commonly used in high-cost specialty drugs

commercial insurance-  Coverage for medical or prescription costs provided by an employer or purchased by an individual; also called private insurance.

coordination of benefits (COB)- Online billing of both a primary and secondary insurer.

Copayment- The amount that the patient is to pay for each prescription as determined by the insurance carrier.

days’ supply- The time that a given amount of prescribed medication lasts a patient until the next refill; required on drug claims submitted for online insurance billing.

Deductible- An amount on some insurance plans that must be paid by the insured person before the insurance company considers paying its portion of a medical or drug cost.

donut hole- An insurance coverage gap in Medicare Part D programs under which the patient must pay a higher portion of the cost of the medication; to be phased out by 2019.

dual copay- Insurance coverage in which a patient pays one copay for brand name drugs and a lower copay for generic drugs; also known as a two-tier.

dual eligible- A patient who has both a primary and secondary insurance plan.

DME(durable medical equipment)- Medically necessary, reusable equipment such as nebulizers, hospital beds, wheelchairs, and walkers that may be purchased in a community pharmacy or billed to Medicare Part B.

first party- The person who directly receives the benefits of a service or product and is responsible for paying for it.

group number- An important piece of information on the insurance card that identifies the employer sponsor of the drug insurance program.

health insurance- Coverage of incurred medical costs, such as physician and emergency room visits, laboratory costs, and hospitalization. 

health savings accounts(HSAs)- Savings accounts that can be started by patients or their employers to set aside tax-deferred money specifically for healthcare costs not covered by their insurance.

healthcare exchange- An online shopping tool to find insurance for the uninsured or self insured; made possible by the Affordable Care Act. 

ICD-10 (The International Classification diseases)- 10th revision; a coding system used by prescribers and insurance companies to offer billing codes for specific diagnoses and diseases.

in-network providers- Prescribers and pharmacies that have a contract with the insurance provider.

Medicaid- A state governmental health insurance program for low-income and disabled citizens/

 \n

Medicare- health insurance primarily for patients over age 65.

PART A - Federally sponsored insurance plan that covers 80% of the cost of hospital stays, as well as limited coverage of skilled nursing facilities, rehabilitation, and home health care; drugs are not covered under this pain.

PART B- Federally sponsored insurance that partially covers the cost of outpatient doctor visit; may cover the cost of nebulizer, and ne

PART C- Federal- and state- sponsored insurance that covers both health and prescription insurance from the same insurance provider; also called a Medicare advantage plan; may include coverage for eye and hearing examinations, glasses, hearing aids, etc.

PART D-  A federal- and state- partnered insurance program that provides partial coverage of prescriptions, primarily for patients who are eligible for Medicare.

Medigap insurance- Private insurance coverage in addition to Medicare Part B That covers a portion of the costs for outpatient physician visits as well as laboratory and x-ray fees not covered by Medicare Part B.

NPI( national Provider Identifier)- The unique number assigned to the provider by the federal government to allow authorized healthcare providers to process insurance claims for pharmacy reimbursement.

online adjudication- real-time insurance claims processing via electronic wireless.

out-of network providers- Prescribers and pharmacies that do not have a contract with the insurance provider; the cost of services is generally higher.

Patient ID number- Identifies the primary drug insurance card holder and may identify other dependents on the policy.

Person code- A two- or three digit number added to the patient identification number listing family members covered by the insurance plan. 

PBM(Pharmacy benefits manager)- A company that administers drug benefits for many insurance companies.

preferred drug list- A formulary provided by an insurance company that indicates preferred prescription generic and brand name drugs and their corresponding copays.

PPO(Preferred provider organization)- Private practice prescriber that has signed a contract with the health insurer to provide services at a discount rate. 

Prescription drug insurance- Specifically covers some of the cost for medications.

PA(Prior authorization)- Approval for coverage of a high-cost medication or a medication not on the insurer’s approved formulary obtained after a prescriber calls the insurer to justify the use of the drug; must be obtained before the drug is dispensed by the pharmacy to be covered by the insurance.

PCN(Processor control number)- An important piece of information located on most drug insurance cards to identify the correct PBM in order to process a prescription claim.

Tricare- Government insurance program for active and retired military and their families.

workers compensation- Insurance provided for a patient with a medical injury from a job-related accident; also called workers’ comp or workman’s comp.