Pharmacy Billing and Insurance Flashcards
6 cards from real Pharmacy practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Pharmacy Billing and Insurance flashcards as text
What does 'coordination of benefits' mean in pharmacy billing?
Answer: Determining which insurer pays first when a patient has multiple plans
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.
Which National Drug Code (NDC) segment identifies the specific package size of a medication?
Answer: Package code (last 2 digits)
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.
A pharmacy submits a claim and receives an 'eligibility not found' rejection. What is the most likely first step?
Answer: Verify the patient's insurance ID, group number, and date of birth
An eligibility rejection typically results from a data entry error, so verifying and correcting the patient's insurance information is the appropriate first step.
What is the purpose of a prior authorization (PA) in pharmacy?
Answer: To obtain insurer approval before dispensing a non-formulary or restricted drug
A prior authorization requires the prescriber to submit clinical justification to the insurance plan before the plan will cover a specific medication.
Which claim field is used to report the prescriber's NPI number?
Answer: NCPDP field 411-DB (Prescriber ID)
The prescriber's NPI is reported using NCPDP field 411-DB along with a qualifier indicating the NPI identifier type.
A drug is classified as Tier 3 on a formulary. What does this typically mean for the patient?
Answer: Higher co-pay, usually for non-preferred brand drugs
Tier 3 on most insurance formularies represents non-preferred brand-name drugs that carry a higher co-pay than preferred generics or preferred brands.