PTCB - Pharmacy Billing and Reimbursement
Study online at https://quizlet.com/_hx0v57
1. 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.
2. 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
3. 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.
4. medicare part D: a federally funded health care program that provides a patient with coverage for select
prescription medications, medical supplies, insulin, and vaccinations.
5. 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
6. average wholesale price: the average price that wholesalers sell a medication
7. actual acquisition cost: actual cost a pharmacy paid for a medication
8. formulary: a list of medications approved for use or reimbursement under a prescription plan.
9. open formulary: a variety of several medications in each therapeutic classification
10. closed formulary: a very limited number of medications available in each therapeutic classification, and
sometimes no medications in certain classifications.
11. restricted formulary: a selective, limited, partially closed formulary in which some non-formulary med-
ications are available.
12. 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.
13. National Provider Identifier: a unique number assigned to health care provider, to transmit health
information according to the HIPAA
14. identification number: given to a patient so that their insurance coverage can be authorized by a
pharmacy
15. insurance premium: when an insurance company charges an individual to maintain their insurance
coverage
16. Health Maintenance Organizations: focus on keeping their patients healthy by providing small
co-pays and minimal to no deductibles.
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Study online at https://quizlet.com/_hx0v57
1. 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.
2. 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
3. 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.
4. medicare part D: a federally funded health care program that provides a patient with coverage for select
prescription medications, medical supplies, insulin, and vaccinations.
5. 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
6. average wholesale price: the average price that wholesalers sell a medication
7. actual acquisition cost: actual cost a pharmacy paid for a medication
8. formulary: a list of medications approved for use or reimbursement under a prescription plan.
9. open formulary: a variety of several medications in each therapeutic classification
10. closed formulary: a very limited number of medications available in each therapeutic classification, and
sometimes no medications in certain classifications.
11. restricted formulary: a selective, limited, partially closed formulary in which some non-formulary med-
ications are available.
12. 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.
13. National Provider Identifier: a unique number assigned to health care provider, to transmit health
information according to the HIPAA
14. identification number: given to a patient so that their insurance coverage can be authorized by a
pharmacy
15. insurance premium: when an insurance company charges an individual to maintain their insurance
coverage
16. Health Maintenance Organizations: focus on keeping their patients healthy by providing small
co-pays and minimal to no deductibles.
1/2
