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Pharmacy > Third Party Billing > Flashcards

Third Party Billing Flashcards

1
Q

How does coordination of benefits work? ie. if patient has multiple insurances, which order to submit claims to?

A

ODB first except trillim
Patient plan before spousal plan
For children, order parent’s plans based on parents birthdays
Pay assist cards always secondary

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2
Q

What ID numbers are found on a Greenshield card?

A

Client ID (7) / Plan ID (2)

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3
Q

What is Greenshield’s policy on refills?

A

Refills no earlier than 7 days

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4
Q

What is Greenshield’s policy on reversals?

A

Reversals online up to 12 mths

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5
Q

What is Greenshield’s policy on vacation supply?

A

Vacation supplies allowed, use MV intervention code

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6
Q

What is Greenshield’s policy on initial days supple?

A

Will reject initial day supply claims over 30 days (10 days for high cost meds)

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7
Q

What is Greenshield’s policy on high cost oral meds?

A

Will limit high cost oral meds to max 30 days

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8
Q

What ID numbers are found on an ESI card?

A

Group ID: Plan contract/group number
Client ID: Certificate Number
Carrier ID: 2 digit code

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9
Q

What is ESI’s refill policy?

A

2/3 early refills eg. up to 30 days early for 90 day supply

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10
Q

What is ESI’s policy on reversals?

A

Reversal on claims within 60 days

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11
Q

What is ESI’s policy on days supply?

A

If the days supply is too high it may only pay a portion and have the rest as a copay

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12
Q

What is ESI’s policy on vacation supply?

A

Prior authorization required (pt to call insurance and obtain this; then pharmacy must call to confirm, otherwise subject to audit)

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13
Q

What is ESI’s policy on high cost meds?

A

Does not allow splitting cost of drugs >$9999.99, pt must pay and submit manually

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14
Q

Who does NIHB cover?

A

Non-Insured Health Benefits provide coverage for registered First Nations and recognized Inuit

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15
Q

What ID numbers are found on NIHB cards?

A

Group ID: 080000
Client ID: 9-10 digit registry number
carrier ID: 15

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16
Q

What is NIHB’s policy on reversals?

A

Reversal on claims within 30 days

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17
Q

What’s covered under NIHB?

A

there’s a formulary online, also has LU and EAP like ODB. Also has specific formularies for renal failure, cancer and palliative care. Also has similar process to ODB for no sub.

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18
Q

What is NIHB’s policy on days supply?

A

Benzodiazepines, opioids, & stimulants

limited to 30 days supply only (will not reject, but clawback on audit)

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19
Q

What to do if NIHB Rx is not picked up in 30 days?

A

RTS, reverse original claim and bill for dispensing fee with DIN 55555555 and no markup or cost

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20
Q

What ID numbers are found on Telus Assure (BCE) cards?

A

Group ID: plan/group number
Client ID: Member ID + 2 digit issue number
Carrier ID: 2 digit code

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21
Q

What is Telus Assure (BCE)’s refill policy?

A

2/3 early refills eg. up to 30 days early for 90 day supply

22
Q

What is BCE’s policy on reversals?

A

Reversal on claims within 60 days

23
Q

What is BCE’s policy on vacation supply?

A

Prior authorization required (pt to call insurance and obtain this; then pharmacy must call to confirm, otherwise subject to audit)

24
Q

Does BCE have days supply limits?

A

Yes

25
Q

What are pay-assist cards?

A

Pays for (some or full) cost difference between brand and generic product.

26
Q

What are 3 things to keep in mind about pay assist cards?

A

They can expire anytime
They may have restrictions on days supply or qty
They’re always last payer

27
Q

How can pharmacies obtain payassist cards?

A

contact the manufacturer & request cards via mail

or via the merck mychoice program or innovicare program

28
Q

What does the error code: drug must be authorized mean and what to do about it?

A

Means the insurance requires prior approval before it will cover it, so for eg. google greenshield prior approval form and have the pt bring it to the dr to fill out and fax to insurance provider. May take a few business days to get approved, pharmacy will not be notified, just submit a claim and see it if works

29
Q

What does the error code: SA – PREFERRENCE OR STEP DRUG AVAILABLE mean and what can be done about it?

A

Some drug plans have step therapy programs, this means they’ll only cover step 2 drugs if the pt is on step 1 drugs eg. metformin. If pt had been on a step 2 drug before starting this insurance, use intervention code UP: FIRST LINE THERAPY INEFFECTIVE or UQ: FIRST LINE THERAPY NOT TOLERATED BY PATIENT

30
Q

Easiest way to see if insurance will cover a certain compound?

A

Just call the insurance. Otherwise Greenshield, ESI, NIHB and Telus Assure have Pseudo-din list, compound criteria and exclusions online

31
Q

pt has own and spousal insurance plan, own plan wont cover med and spousal plan says to submit to own plan first, what’s the intervention code?

A

DB: SECONDARY CLAIM - ORIGINAL TO OTHER

CARRIERS

32
Q

pt has ODB and third party insurance, med only partly covered by ODB, what intervention code to use to submit to insurance?

A

DA: SECONDARY CLAIM - ORIGINAL TO

PROVINCIAL PLAN

33
Q

patient has had dose change, needs early refill but insurance says refill too soon, what’s the intervention code?

A

MN: REPLACEMENT CLAIM DUE TO DOSE

CHANGE

34
Q

trying to split a claim for >$9999, but now insurance says days supply too low, what’s the intervention code?

A

MG: OVERRIDE FOR VARIOUS REASONS

35
Q

intervention code to override DDI error from insurance?

A

UG: CAUTIONED PATIENT. RX FILLED AS WRITTEN

36
Q

patient on step 2 therapy, starting new insurance but claim not going through bc insurance wants them to try step 1 therapy first, what intervention codes to use?

A

UP: FIRST LINE THERAPY INEFFECTIVE
UQ: FIRST LINE THERAPY NOT TOLERATED BY PATIENT

37
Q

patient has ODB and greenshield, wants a med that’s EAP but greenshield won’t cover it, why?

A

Greenshield will only cover if the pt has applied for EAP and been rejected or is pending; use intervention codes
DX: APPLIED TO PROV. PLAN, DECISION PENDING
DW: APPLIED TO PROV. PLAN AND REJECTED

38
Q

patient with greenshield wants vacation supply but error days supply exceeded, what intervention code?

A

MV: VACATION SUPPLY

39
Q

patient has 30 days left on a prescription but greenshield gives error bc less than 90 days supply, what intervention code to use?

A

ER: OVERRIDE DAYS SUPPLY LIMIT FOR PERIOD

40
Q

patient has ODB and greenshield, prescribed an LU med but doesn’t meet LU criteria, what intervention code to get GS to cover it?

A

MS: NON-FORMULARY BENEFIT

41
Q

what intervention code to override greenshield’s initial day supply program?

A

NH: INITIAL RX PROGRAM DECLINED
NF: OVERRIDE - QUANTITY APPROPRIATE (when you can’t split the qty due to packaging)

42
Q

patient on ODB and ESI prescribed an LU product but still waiting to hear from Dr whether they qualify

A

MU: LIMITED USE PRODUCT
PC: PATIENT DOES NOT MEET EXCEPTION
CRITERIA

43
Q

Billing Telus Assure for suboxone/methadone today’s dose + carries, but error code for identicle claim, what’s the intervention code?

A

NA = VALID CLAIM – PRIMARY VALIDATION

LEVEL

44
Q

Billing Telus Assure and splitting claim for high cost med but error code for identicle claim

A

NA = VALID CLAIM – PRIMARY VALIDATION

LEVEL, only charge 1 markup, call before u do this

45
Q

How is drug coverage provided for refugees?

A

Coverage similar to ODB provided via the Interim Federal Health Program (IFHP) through Medavie Blue Cross.
Group: 91011 Client: UCI 8 digit number Carrier: CO
Call 1-888-614-1880 to confirm IFHP coverage

46
Q

How is WSIB coverage billed?

A 
Under Telus Assure
Group ID: 2000 
Client ID: 12 digit claim number + 01 
Carrier ID: 49
WSIB is the ONLY payer, no coordination of benefits
47
Q

What does WSIB cover?

A

Pays for prescription drugs for workers related to workplace injury/illness. There is a formulary but each drug to be approved for work-related injury/illness

48
Q

What is the Ontario Monitoring for Health

Program?

A

Program for Ontario residents who use insulin/have gestational diabetes and have no other coverage for supplies being claimed. Will cover 75% of cost (within certain max limits) of:
• BG test strips, lancets, BG meters, talking BG meters
• ODB recipients: lancets only
But patient or pharmacy must submit form manually for reimbursement.

49
Q

If child has coverage from 2 parents, which goes first?

A

Based on whoever’s birthday is first, and if same birthday then based on alphabetical order of the parents first name.

50
Q

Resource for student insurance coverage

A

Studentrx

Pharmacy (43 decks)

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