Third Party Payer Information and Claims Processing

  • Identifying Third Party Payer Information

    • Essential for processing prescriptions
    • Patients may have multiple insurance cards

  • Key Numbers for Claims Submission

    • Processor Bank Identification Number (BIN): 6-digit number for electronic routing
    • Processor Control Number (PCN): Alphanumeric identifier for pharmacy claims
    • Member Identification Number: Unique to the primary insurance holder
    • Person Code: Identifies household members using the plan
    • Prescription Group Number: Indicates the insurance plan and typically relates to the employer

  • Claim Submission Process

    • Claims processed electronically—different from medical claims
    • Payments transferred automatically from insurance to pharmacy

  • Rejection Codes

    • Standardized by National Council for Prescription Drug Programs (NCPDP)
    • Can indicate dose changes, modifications required, or missing information
    • Prior Authorization Required: Additional information needed from the provider

  • Insurance Providers and Formularies

    • Only approved medications covered
    • Non-formulary medications require alternative solutions

  • Coordination of Benefits (COB)

    • Determines primary versus secondary insurance claims
    • Avoids duplicate payments and ensures claims meet 100% coverage

  • Medicare Billing for Durable Medical Equipment (DME)

    • Requires paper claim submission for Medicare Part B
    • Stringent documentation needed to avoid issues during audits

  • Filling Guidelines for Diabetes Supplies

    • Supplies covered under Medicare Part B with specific documentation requirements

  • Important Contact Information

    • Prescribers may need to provide additional authorizations for medications
    • Manufacturer assistance programs available for costly medications

  • Audit Considerations

    • Accurate documentation required for all claims to prevent reimbursement issues.