Billing and Reimbursement Flashcards
(60 cards)
What company focuses on the pharmacy services provided under a health care plan?
Pharmacy Benefit Management Company
What word means paying a fixed prepaid fee per person to provide a range of health services; paid before services are provided?
Capitation
What is a set fee paid for each type of service that is performed and is paid at the time of service?
Fee for service
What is a care provider where the primary care physician directs all medical care for patient, a proactive instead of reactive health care and the goal of it is to keep patient healthy?
Health Maintenance Organizations (HMO)
What care provider provides provides health care services at a discounted fee for services. and insurance pays a percentage of the bill?
Preferred Provider Organizations (PPO)
What care provider allows you to choose between HMO and PPO for services, direct medical care is the primary care provider (PCP), and members can see out-of-network providers but at a higher cost and premium.
Point of service plans (POS)
What is a hybrid of PPO, but does not make payments to an outside provider?
Exclusive Point of Service (EPOS)
What are financial accounts that are established by an individual or family t pay for qualified medical expenses?
Health savings account
What plan is it when a patient obtains a patient drug card from a pharmacy benefits manager and are very expensive?
Private plans
Who can use medicare?
They are for people 65 years or older NOT based on income
How many parts of medicare are there and what do they cover?
There are four parts.
- Part A covers inpatient care like hospice and the hospital.
- Part B covers outpatient care like physical therapy
- Part C offers alternate way to get benefits for Part A or B through PPO or HMO at a high price
- Part D: provides prescription drug coverage like insulin and vaccines
Who uses Medicaid?
Medicaid is controlled by the federal and state as a program based on income
What is AWP and what is it?
It stands for average wholesale price.
-it is the average price wholesalers sell medication
What does AAC stand for and what is it?
It stands for actual acquisition cost.
It is the actual cost the pharmacy paid for medication
What does MAC stand for and what is it?
It stands for max allowed cost.
It is determined by managed care organizations
What does formulary usage mean?
it is a list medications approved for use or reimbursement under prescription plan
What is a open formulary?
a list of medications where a variety of drugs are available
What is a close formulary?
A list of medications which limits access of a practitioner to some medication
What is a restricted formulary?
where selective drugs are available
What is the formulary exception process?
It is the right to use formulary and nonformulary medication to be dispensed
What is a formulary override?
It is the process that requires physician to request for approval to prescribe a nonformulary medication and document reason for the medication
What is Prior authorization?
when the phycisian obtains approval form the health insurance plan to prescribe a specific medication for you
List the information contained in a prescription drug card
- BIN (bank identification number)
- Plan code
- Issuer
- ID
- subscriber name
- copays
- help desk telephone number
- DAW codes
What does DAW 0 mean?
no production selection is indicated
