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Flashcards in Pharmacy Billing And Reimbursement Deck (50)
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1

Which of the following types of insurance plans are federal programs for patients who are elderly, disabled, reveiviong dialysis, or low-income?
A. Preferred provide organization (PPO)
B. Workers’ compensation
C. Medicare and Medicaid
D. Health maintenance organization (HMO)

C. Medicare and Medicaid

2

A Rx drug may require PRIOUR AUTHORIZATION from an insurance company in which of the following circumstances?
A. It is a medication used for cosmetic purposes
B. it is a brand name medication that has a generic availability
C. It is a medication that is being used at higher than normal doses
D. All of the above

D. All of the above

3

Which of the following is an employer-sponsored benefit that allows employees to use pre-tax dollars to pay for eligible health care expenses?
A. Capitation account
B. Fee-for-service account
C. Flexible spending account (FSA)
D. Reimbursement account

C. Flexible spending account (FSA)

4

Which of the following parts of Medicare is a private insurance option that is also known as MEDICARE ADVANTAGE?
A. Part A
B. Part B
C. Part C
D. Part D

C. Part C

5

Which of the following refers to the process that requires a prescriber to obtain approval from a patient’s insurance company before a specific medication can be dispensed?
A. Initial authorization
B. Prior authorization
C. Coordination of benefits
D. None of the above

B. Prior authorization

6

Which of the following information is needed by an insurance company when a pharmacy submits a claim for a Rx?
A. Lot number of medication
B. Patient’s address
C. Patient’s DOB
D. Expiration date of medication

C. Patient’s DOB

7

A _____ fee compensates a pharmacy for transferring a drug to the patient, overhead costs, and patient counseling.
A. Deductible
B. Co-pay
C. Dispensing
D. Capitation

C. Dispensing

8

Health care saving plans were created under which of the following laws?
A. Omnibus Budget Reconciliation Act of 1990
B. HIPPA Act of 1996
C. Kefauver-Harris Amendement of 1962
D. Medicare Rx Drug, Improvement, and Modernization Act of 2003

D. Medicare Rx Drug, Improvement, and Modernization Act of 2003

9

Which of the following refers to the amount of money that must be paid on an annual basis before a co-pay applies?
A. Premium
B. Co-insurance
C. Deductible
D. Capitation

C. Deductible

10

In an institutional setting, patients are billed for medications based on information that is provided from which of the following?
A. Formulary
B. Medication Administration Record (MAR)
C. Pyxis record
D. Progress notes

B. Medication Administration Record (MAR)

11

Which of the following terms refers to the process of a pharmacy submitting Rx claims to a 3rd-party provider?
A. PA
B. Adjudication
C. Coordination of benefits
D. Remittance advice

B. Adjudication

12

The Red Book is a resource used to find which of the following?
A. Invoice cost
B. Percent markup
C. Average wholesale price (AWP)
D. Net profit

C. Average wholesale price (AWP)

13

Which of the following parts of Medicare covers DOCTOR VISITS and OUTPATIENT SERVICES?
A. Part A
B. Part B
C. Part C
D. Part D

B. Part B

14

ALL BUT WHICH of the following statements are true regrading Rx drug plans?
A. All Rx drug benefit plans have a deductible
B. Some Rx drug plans have a mail-order pharmacy option
C. Many Rx drug plans have tiered co-pays
D. Employers are not required to provide Rx drug benefits

A. All Rx drug benefit plans have a deductible

15

Which of the following refers to the average purchase price of a medication at the wholesale level?
A. Actual acquisiton cost (AAC)
B. Maximum allowable cost (MAC)
C. Direct wholesale cost (DWP)
D. None of the above

D. None of the above

16

Which of the following is a unique 10-digit ID number issued to health care providers to transmit health information?
A. DEA number
B. ID number
C. National Provider Identifier (NPI)
D. Bank Identification number (BIN)

C. National Provider Identifier (NPI)

17

Deductibles for a R insurance plan are reset ______.
A. Every month
B. Every 5 months
C. Every calender year
D. Every 2 years

C. Every calender year

18

Which of the following parts of Medicare covers certain VACCINES that are administered to a patient at a PHARMACY?
A. Part A
B. Part C
C. Part D
D. All of the above

C. Part D

19

ALL BUT WHICH of the following strategies are used by pharmacy benefit managers to contain drug costs?
A. Tiered co-pay structure
B. Initial co-pay structure
C. PA
D. Formulary management

B. Initial co-pay structure

20

In which of the following types of insurance plants can a patient choose a PCP from a network of providers, and that physcian coordinates his/her care?
A. HMO
B. PPO
C. Civil labor union
D. Workers’ compensation organization

A. HMO

21

Which of the following types of co-payment arrangement requires a set co-pay regardless of the medication recieved and its cost?
A. Percentage co-pay
B. Multitier co-pay
C. Variable co-pay
D. None of the above

D. None of the above

22

Which of the following steps should be performed if a “Patient Not Eligible” aler occurs when billing an insurance company for a Rx?
A. Verify patient’s name and DOB
B. Verify a patient’s code
C. Check that the correct insurance company is being billed
D. All of the above

D. All of the above

23

Which of the following refers to the percentage cost that a patient pays for a medication?
A. Deductible
B. Co-pay
C. Tiered formulary
D. Co-insurance

D. Co-insurance

24

Which of the following describes an alphanumeric number defined by a pharmacy benefit manager that appears on a health insurance card and is used as a SECONDARY identifier for insurance claims?
A. BIN
B. Member ID number (MIN)
C. Processor control number (PCN)
D. Group number

C. Processor control number (PCN)

25

Which of the following parts of Medicate offers Rx drug plans?
A. Part A
B. Part B
C. Part C
D. Part D

Part D

26

Which of the following refers to the coverage gap in Medicare Part D that occurs when the cost of a patient's Rx in a given year exceeds a certain amount?
A. Benefit Limitations
B. Capitation
C. Stop-loss limit
D. Donut hole

D. Donut Hole

27

Drug coupon cards for specific medication are provided by:
A. Wholesalers
B. Manufacturers
C. Insurance companies
D. Distributors

B. Manufacturers

28

Which of the following is extra health insurance that covers the gap in the Medicare program coverage?
A. Stop-loss coverage
B. Health savings account
C. Flexible savings account
D. Medigap

D. Medigap

29

Which of the following refers to the max amount that a plan will pay for generic drugs and brand name drugs that have a generic available?
A. Suggested wholesale price (SWP)
B. Average wholesale price (AWP)
C. Maximum allowable cost (MAC)
D. Actual acquisition cost (AAC)

C. Maximum allowable cost (MAC)

30

ALL BUT WHICH of the following are examples of government-sponsored health insurance programs?
A. Medigap
B. Medicare
C. Medicaid
D. TRICARE

A. Medigap