PHARMACY BILLING REIMBURSEMENT TECHNICIAN CERTIFICATION 2026 Latest Study Guide with Practice Questions Insurance Claims Review • Verified Answers • Detailed Rationales • Success Workbook

PHARMACY BILLING REIMBURSEMENT
TECHNICIAN CERTIFICATION 2026 Latest Study
Guide with Practice Questions Insurance Claims
Review • Verified Answers • Detailed Rationales •
Success Workbook

EXAM INSTRUCTIONS:
• Select the single best answer for each question
• Each question is designed to test critical knowledge for the Pharmacy Billing
Reimbursement Technician Certification
• Answers are highlighted in bold for quick reference
• Detailed rationales are provided for comprehensive understanding


SECTION 1: PHARMACY BILLING FUNDAMENTALS
Question 1:
A pharmacy technician is processing a claim for a Medicare Part D beneficiary.
Which of the following correctly identifies the primary billing system used for
Medicare Part D claims?
A) CMS-1500 form submission
B) UB-04 form submission
C) NCPDP D.0 format
D) Paper HCFA-1450 format
Rationale: The National Council for Prescription Drug Programs (NCPDP) D.0
format is the standard electronic transaction format required for Medicare Part D
prescription drug claims. CMS-1500 is used for professional medical claims, UB-
04 for institutional claims, and HCFA-1450 is an outdated form.


Question 2:
What is the primary purpose of the NCPDP Telecommunication Standard?

,A) To standardize medical diagnoses coding
B) To standardize electronic transmission of pharmacy claims
C) To regulate pharmacy technician certification
D) To establish medication pricing guidelines
Rationale: The NCPDP Telecommunication Standard provides a uniform format
for transmitting prescription drug claims between pharmacies, payers, and
clearinghouses, ensuring interoperability across the pharmacy industry.


Question 3:
Which of the following entities is responsible for creating and maintaining the
National Drug Code (NDC) system?
A) Centers for Medicare & Medicaid Services (CMS)
B) American Medical Association (AMA)
C) Food and Drug Administration (FDA)
D) Drug Enforcement Administration (DEA)
Rationale: The FDA establishes and maintains the NDC system under the Drug
Listing Act of 1972. CMS uses NDC numbers for billing, but CMS does not create
them. The AMA creates CPT codes, and the DEA regulates controlled substances.


Question 4:
A pharmacy technician receives a claim rejection with the code "M/I Patient ID."
What does this error indicate?
A) Medication is not covered
B) Missing or invalid patient identification number
C) Prior authorization required
D) Refill too soon
Rationale: "M/I" stands for "Missing/Invalid." Patient ID rejection indicates the
submitted patient identification number does not match the payer's records or was
not provided in the required format.

,Question 5:
Which of the following best describes the "days supply" field in a pharmacy claim
submission?
A) The number of days until the prescription expires
B) The number of days the medication has been on the market
C) The calculated number of days the prescribed medication will last based on
the directions for use
D) The number of days until the next refill is due
Rationale: Days supply is calculated based on the quantity dispensed divided by
the daily dosage, indicating how long the medication will last for the patient. This
directly impacts billing, reimbursement, and refill dates.


Question 6:
What is the purpose of the Drug Utilization Review (DUR) process in pharmacy
billing?
A) To determine the cost of medications
B) To process prior authorization requests
C) To identify potential drug interactions, duplications, and therapy issues
D) To verify patient demographics
Rationale: DUR screens for clinical issues including drug-drug interactions, drug-
disease contraindications, duplicate therapy, incorrect dosage, and therapeutic
appropriateness. It is a safety measure required in claim processing.


Question 7:
Which of the following is NOT a required element on a CMS-1500 claim form?
A) Patient name and date of birth
B) Provider NPI number
C) Diagnosis codes
D) Patient's social security number
Rationale: While patient identifiers are required, the patient's social security
number is not a required field on the CMS-1500. Patient ID numbers, name, DOB,
and insurance information are required.

, Question 8:
When submitting a claim to a commercial insurance plan, what is the significance
of the "BIN" number?
A) Bank Identification Number - identifies the processor for electronic claims
B) Benefit Identification Number - identifies the plan's benefit structure
C) Billing Identification Number - identifies the pharmacy provider
D) Basic Insurance Number - identifies the primary insurance
Rationale: In pharmacy billing, BIN (Bank Identification Number) identifies the
claims processor or clearinghouse that will route the claim to the correct payer.
PCN (Processor Control Number) may also be required.


Question 9:
What is the correct procedure when a claim is rejected with a "Prior Authorization
Required" message?
A) Resubmit the claim with a different diagnosis code
B) Change the medication to a generic alternative
C) Obtain prior authorization from the prescriber and payer before
dispensing
D) Bill the patient directly without insurance
Rationale: Prior authorization is a process where the prescriber must obtain
approval from the insurance company before the medication will be covered. The
pharmacy should not dispense until authorization is secured and documented.


Question 10:
Which Medicare program provides prescription drug coverage?
A) Medicare Part A
B) Medicare Part B
C) Medicare Part D
D) Medicare Part C
Rationale: Medicare Part D is the outpatient prescription drug benefit program.
Part A covers hospital inpatient services, Part B covers medical services and some