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PTCB - Pharmacy Billing and Reimbursement Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

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PTCB - Pharmacy Billing and Reimbursement Questions and Answers | Latest Version | 2025/2026 | Correct & Verified What is the primary purpose of pharmacy billing? To ensure accurate payment for medications dispensed. Which form is commonly used to submit pharmacy claims to insurance companies? CMS-1500 or electronic claim forms. What does the acronym NPI stand for in pharmacy billing? National Provider Identifier. Which code set is used to identify diagnoses for reimbursement? ICD (International Classification of Diseases) codes. Which code set is used to identify procedures for billing purposes? CPT (Current Procedural Terminology) codes. 2 What is the purpose of the DUR (Drug Utilization Review)? To check for appropriate, safe, and effective medication use. Which government program provides pharmacy coverage for elderly and disabled patients? Medicare. What is the difference between copay and coinsurance? Copay is a fixed amount; coinsurance is a percentage of the cost. Which form of pharmacy reimbursement involves a third-party payer paying directly to the pharmacy? Third-party reimbursement. What does the acronym MAC stand for in pharmacy billing? Maximum Allowable Cost. Which pharmacy billing document lists all medications dispensed to a patient during a visit? 3 Patient Medication Profile. What is prior authorization in pharmacy billing? Approval from insurance before dispensing certain medications. Which government program provides healthcare coverage for low-income individuals, including pharmacy benefits? Medicaid. What does DAW code indicate in pharmacy claims? Dispense As Written. Which type of insurance plan requires patients to use specific pharmacies or pay more? Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO) restrictions. Which form is used for electronic pharmacy claim submission? NCPDP (National Council for Prescription Drug Programs) claim standard. 4 What is adjudication in pharmacy billing?

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PTCB - Pharmacy Billing and
Reimbursement Questions and
Answers | Latest Version | 2025/2026 |
Correct & Verified
What is the primary purpose of pharmacy billing?


✔✔ To ensure accurate payment for medications dispensed.




Which form is commonly used to submit pharmacy claims to insurance companies?


✔✔ CMS-1500 or electronic claim forms.




What does the acronym NPI stand for in pharmacy billing?


✔✔ National Provider Identifier.




Which code set is used to identify diagnoses for reimbursement?


✔✔ ICD (International Classification of Diseases) codes.




Which code set is used to identify procedures for billing purposes?


✔✔ CPT (Current Procedural Terminology) codes.


1

, What is the purpose of the DUR (Drug Utilization Review)?


✔✔ To check for appropriate, safe, and effective medication use.




Which government program provides pharmacy coverage for elderly and disabled patients?


✔✔ Medicare.




What is the difference between copay and coinsurance?


✔✔ Copay is a fixed amount; coinsurance is a percentage of the cost.




Which form of pharmacy reimbursement involves a third-party payer paying directly to the

pharmacy?


✔✔ Third-party reimbursement.




What does the acronym MAC stand for in pharmacy billing?


✔✔ Maximum Allowable Cost.




Which pharmacy billing document lists all medications dispensed to a patient during a visit?


2
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