PTCB - Pharmacy Billing and Reimbursement Latest Update with Verified Solutions

PTCB - Pharmacy Billing and Reimbursement Latest Update with Verified Solutions medicare advantage (medicare part C) allows participants in Medicare Part A and B to obtain coverage through a Health Maintenance Organization or Preferred Provider Organization that provides additional services at a higher cost. medicare part A a federally funded health care program that pays for a patient's inpatient hospital care, skilled nursing care, hospice care, and home health care medicare part B a federally funded health care program that provides a patient with coverage for physician visits, outpatient care, physical therapy, and occupational therapy. medicare part D a federally funded health care program that provides a patient with coverage for select prescription medications, medical supplies, insulin, and vaccinations. Medicaid a federal program based on income as well as other circumstances. eligibility is determined on a month by month basis. it generally covers doctors visits, emergency care, hospital care, vaccinations, prescriptions, vision, hearing, and preventative care for children average wholesale price the average price that wholesalers sell a medication actual acquisition cost actual cost a pharmacy paid for a medication formulary a list of medications approved for use or reimbursement under a prescription plan. open formulary a variety of several medications in each therapeutic classification closed formulary a very limited number of medications available in each therapeutic classification, and sometimes no medications in certain classifications. restricted formulary a selective, limited, partially closed formulary in which some non-formulary medications are available. online adjudication the process by which a pharmacy submits prescription claims electronically to a third party provider when filling a prescription to ensure accurate copayments and timely payment. it allows the pharmacy to verify a patient's eligibility and to determine the plan name, patient identification, and group number from Medicare. National Provider Identifier a unique number assigned to health care provider, to transmit health information according to the HIPAA identification number given to a patient so that their insurance coverage can be authorized by a pharmacy insurance premium when an insurance company charges an individual to maintain their insurance coverage Health Maintenance Organizations focus on keeping their patients healthy by providing small co-pays and minimal to no deductibles. Preferred Provider Organizations offer health care services for a discounted fee by using non-exclusive contracts with network providers. Point of Service Plans require their patient to use their primary care physicians to direct their medical care but allow its members to see out of network providers at a higher cost. Bank Identification Number a six digit number used to ID the company that will reimburse the pharmacy for the prescription being filled plan code denotes the prescription provider group code shows the patient's employer issuer the health insurance company who issued the insurance card. Drug Topics Red Book online resource listing the updated average wholesale price of all drugs DAW 1 code used when a prescriber request a brand name product to be dispensed DAW 2 code used when a patient requests a brand name product to be dispensed DAW 3 code used when a pharmacist requests a brand name product to be dispensed DAW 4 code used when a pharmacy does not have a generic drug in stock and dispenses the brand name product instead DAW 7 code used when the prescriber allows the generic form to be dispensed, but the law requires the brand form to be dispensed DAW 8 code used when the prescriber allows the generic form to be dispensed, but the generic form is not available on the market Prior Authorization when an insurance company requires a prescriber to state why they ordered a particular drug for a patient before the insurance company will cover the drug. DAW 6 code used as an all purpose dispense as written override DAW 0 code used when the prescriber allows the generic form to be dispensed DAW 9 code used as an "other" override DAW 5 code used when the prescriber allows the generic from to be dispensed but the pharmacy dispenses the brand form as the generic form.