Pharmacy Pharmacy Billing and Insurance 2

Question 1

What does 'coordination of benefits' mean in pharmacy billing?

Accepted Answer

Determining which insurer pays first when a patient has multiple plans

Answer

Coordination of benefits (COB) is the process of determining the order in which multiple insurance plans pay for a patient's prescription to prevent overpayment.

Question 2

Which National Drug Code (NDC) segment identifies the specific package size of a medication?

Accepted Answer

Package code (last 2 digits)

Answer

The NDC is an 11-digit code in 5-4-2 format; the last 2-digit segment is the package code identifying the package type and size.

Question 3

A pharmacy submits a claim and receives an 'eligibility not found' rejection. What is the most likely first step?

Accepted Answer

Verify the patient's insurance ID, group number, and date of birth

Answer

An eligibility rejection typically results from a data entry error, so verifying and correcting the patient's insurance information is the appropriate first step.

Question 4

What is the purpose of a prior authorization (PA) in pharmacy?

Accepted Answer

To obtain insurer approval before dispensing a non-formulary or restricted drug

Answer

A prior authorization requires the prescriber to submit clinical justification to the insurance plan before the plan will cover a specific medication.

Question 5

Which claim field is used to report the prescriber's NPI number?

Accepted Answer

NCPDP field 411-DB (Prescriber ID)

Answer

The prescriber's NPI is reported using NCPDP field 411-DB along with a qualifier indicating the NPI identifier type.

Pharmacy Practice Test

Pharmacy Practice Test

Pharmacy Pharmacy Billing and Insurance 2