Formularies
What's the difference between an open and closed formulary?
Open covers most drugs, closed only covers selected ones
Which type usually requires a primary care provider (PCP)?
HMO
A set amount a patient pays before coverage starts.
Claim rejected as "Too early to refill." What went wrong?
Which law prohibits false statements in claims?
False Claims Act
What's a prior authorization (PA) and why is it needed?
Doctor approval required for certain costly/high-risk drugs
Which allows specialists without referrals but costs more out-of-network?
PPO
Portion patient pays at time of service.
Co-pay
Claim says "Patient not covered." Possible reasons?
Wrong insurance info, incorrect DOB, new coverage
Which law prohibits giving incentives for referrals?
Anti-Kickback Statute
What are the 3 common tiers in a formulary?
Generic, brand name, non-preferred
Which program covers individuals 65+ or those with end-stage renal disease?
Medicare
What does "adjudication" mean?
Electronic processing of a claim for approval/payment
Why should techs not take error messages at face value?
Need to verify with patient/insurance; messages can be misleading
Which statue prohibits doctors from referring to clinics they have financial interests in?
Stark Statute
Who enforces use of formularies through DURs?
Pharmacy Benefit Managers (PBMs)
Which insurance covers disabled veterans and their families?
CHAMPVA
What does DAW mean?
Dispense As Written
What should the technician do if a claim keeps rejecting?
Investigate, ask patient, contact insurance
Which act created auditing reforms to prevent corporate fraud?
Sarbanes-Oxley Act
What is the purpose of a drug utilization review (DUR), and what are two issues it checks for before approving a prescription?
DURs ensure safe, effective, and cost-effective medication use. They check for formulary compliance, eligibility, dosage accuracy, drug interactions, and disease interactions
Compare TRICARE for Life with TRICARE Prime in terms of who is covered and how payment works.
TRICARE Prime acts like an HMO for active duty and families, TRICARE for Life covers military retirees and works as a secondary insurance after Medicare
What is the difference between a claim and adjudication, and why are both essential in the billing process?
A claim is the request for reimbursement submitted to insurance. Adjudication is the electronic review/approval process of that claim by the insurer or processor. Both are essential because claims request payment, and adjudication determines approval/payment
A prescription claim rejects with the message “Patient not covered”. List three possible reasons AND describe the steps a technician should take to resolve it.
Reasons: wrong insurance company entered, incorrect name (nickname, marriage/divorce), incorrect birth date, or new coverage not yet updated. Steps: verify patient information, confirm insurance details with patient, contact insurance company for clarification
Name and briefly describe three different laws/statutes related to insurance fraud that pharmacy technicians should know.
False Claims Act – prohibits submitting false claims/statements for payment.Anti-Kickback Statute – prohibits giving/receiving incentives for patient referrals.
Stark Statute – prohibits doctors/family from referring to clinics they have financial interests in.
(Other possible: Sarbanes-Oxley Act – corporate responsibility/accounting reforms)