CPhT CPhT Insurance and Billing 2 — Questions and Answers
Question 1: What does 'COB' stand for in pharmacy billing?
- Cost of Benefits
- Coordination of Benefits (Correct answer)
- Certificate of Billing
- Controlled Order Balance
Correct answer: Coordination of Benefits
COB (Coordination of Benefits) is the process of determining which insurance plan pays first when a patient has multiple insurance plans.
Question 2: What is a rejected claim in pharmacy billing?
- A prescription the pharmacist refused to fill
- An insurance claim that was not paid due to errors or eligibility issues (Correct answer)
- A medication returned by the patient
- A controlled substance order denied by the DEA
Correct answer: An insurance claim that was not paid due to errors or eligibility issues
A rejected claim occurs when an insurance company does not process a prescription claim, often due to eligibility issues, incorrect information, or coverage limitations.
Question 3: What is the difference between a deductible and a copay?
- There is no difference
- A deductible is a set amount paid before insurance kicks in; a copay is a fixed per-prescription fee (Correct answer)
- A deductible is paid per prescription; a copay is paid annually
- A deductible applies to generics; a copay applies to brand drugs
Correct answer: A deductible is a set amount paid before insurance kicks in; a copay is a fixed per-prescription fee
A deductible is the annual amount a patient must pay before insurance begins covering costs, while a copay is a fixed fee paid for each prescription.
Question 4: What is a step therapy requirement?
- A gradual dose titration protocol
- A requirement to try lower-cost medications before a more expensive one is covered (Correct answer)
- A multi-step compounding procedure
- A training requirement for pharmacy technicians
Correct answer: A requirement to try lower-cost medications before a more expensive one is covered
Step therapy requires patients to try and fail on a preferred (usually cheaper) medication before insurance will cover a more expensive alternative.
Question 5: What does 'NPI' stand for in pharmacy billing?
- National Pharmacy Identifier
- National Provider Identifier (Correct answer)
- New Prescription Invoice
- Non-Preferred Item
Correct answer: National Provider Identifier
NPI (National Provider Identifier) is a unique 10-digit identification number required for all healthcare providers, including pharmacies, for billing purposes.
Question 6: When a pharmacy submits a claim using NCPDP standards, what type of claim is this?
- A paper claim
- An electronic pharmacy claim (Correct answer)
- A Medicare Part A claim
- A compounding claim
Correct answer: An electronic pharmacy claim
NCPDP (National Council for Prescription Drug Programs) standards govern the electronic submission of pharmacy claims to insurance payers.
CPhT CPhT Insurance and Billing 2
What does 'COB' stand for in pharmacy billing?