PTCE PTCE Billing and Reimbursement 2

Question 1

What is the 'usual and customary' (U&C) price in pharmacy billing?

Accepted Answer

The price a pharmacy charges cash-paying customers

Answer

The U&C price is the standard cash price a pharmacy charges, and insurance plans typically reimburse the lower of the U&C or contracted rate.

Question 2

What does 'days supply' mean in the context of a prescription claim?

Accepted Answer

The number of days the dispensed quantity is expected to last

Answer

Days supply is calculated by dividing the dispensed quantity by the daily dose and is required on insurance claims to prevent early refills.

Question 3

What does co-insurance mean in pharmacy benefits?

Accepted Answer

A percentage of the drug cost the patient pays after meeting the deductible

Answer

Co-insurance is the patient's percentage share of the drug cost (e.g., 20%) after their deductible has been met, as opposed to a fixed copay.

Question 4

What does claim rejection code '75' typically indicate?

Accepted Answer

Prior authorization required

Answer

Rejection code 75 means the insurance requires a prior authorization before it will reimburse for the prescribed medication.

Question 5

What is a drug formulary tier system used for?

Accepted Answer

Determining the patient's copay level based on drug category

Answer

Formulary tiers assign drugs to categories (e.g., generics, preferred brands, non-preferred brands) with increasing copay amounts at higher tiers.

(PTCE) Pharmacy Technician Certification Exam Practice Test