Insurance 101
This term refers to the list of medications your insurance plan agrees to cover.
formulary
This Medicare part covers hospital stays.
Part A
The process of submitting and processing a prescription insurance claim is known as this.
adjudication
This type of inventory level tells you the minimum amount that should always be on hand.
PAR (Periodic Automatic Replenishment) level
The tech must always do this before submitting a claim or filling a med.
verify insurance and billing information
True or False: The dependent code identifies if the patient is a child, spouse, or self.
true
What happens to a prescription claim if the patient’s insurance coverage is no longer active .
it gets rejected (or denied)
If a patient doesn't use insurance and pays full price, it's called this.
self-pay
True or False: Techs should override warnings in the computer if they know the patient.
false
This term means rotating drugs so soon-to-expire meds are used first.
stock rotation
This is the amount a patient pays for each prescription, regardless of total cost.
co-pay
This part of Medicare helps pay for prescription drugs.
Part D
A rejection code for “refill too soon” usually means this.
patient is trying to refill before allowed by the plan (usually more than 7 days early)
These machines help track inventory and automatically reorder medications.
automated dispensing systems
This part of the insurance card tells the pharmacy where to send the claim.
RxBIN
This number identifies the cardholder specifically.
Member ID or Subscriber ID
The plan may reject a claim if the refill is requested before this amount of time.
7 days before the due date (or plan’s refill window)
Cards like GoodRx or SingleCare offer these types of savings.
discount programs
When entering a prescription, accuracy is vital to prevent this.
claim rejection
These meds are ordered in bulk and delivered directly from the company.
direct from manufacturer orders
A pharmacy benefit manager (PBM) serves as this between the pharmacy and insurer.
middleman
This program assists spouses and dependents of veterans who are disabled or deceased.
CHAMPVA
Before insurance will cover some high-cost meds, this doctor-submitted paperwork may be required.
prior authorization
Drugs that are rarely used and often sit on the shelf are referred to as this.
slow movers
This is the unique identifier for a specific family member covered under the plan.
person or dependent code
This number groups members under the same employer or policy plan.
Group Number
The process of fixing and sending a claim again is called this.
resubmitting a claim
These are employer-based pre-tax accounts used for medical expenses.
HSA (Health Savings Account) or FSA (Flexible Spending Account)
Before dispensing medication, techs must verify this about insurance.
coverage and patient eligibility
If a medication is only ordered for a specific patient, it’s considered this type of order.
special order
This insurance type requires members to stay in-network and select a PCP.
HMO (Health Maintenance Organization)
This optional policy helps cover what Medicare doesn't pay for—especially in the “donut hole.”
Medigap
This information must match exactly or the claim may be denied: patient’s name, DOB, and this number.
Member ID or insurance ID number
Returned meds may be due to expiration, damage, or this manufacturer action.
recall
This type of order is used when the pharmacy doesn’t normally stock the medication.
special order
This person listed on the card is responsible for the plan and premiums.
primary policyholder
An insurance company might do this if a pharmacy refills prescriptions too early too often.
audit the pharmacy
These short-term savings offers from drug manufacturers can't be used with Medicare/Medicaid.
coupons
This tool is used to scan barcodes and update inventory.
handheld scanner
These types of meds need extra care due to their danger level.
hazardous substances or cytotoxic drugs
This process occurs when a patient has two insurance plans and both are billed
coordination of benefits
Medicare enrollment occurs annually between these dates.
October 15 and December 7
If a claim is rejected, a technician should take these steps (name at least 3).
check the rejection code, fix the problem, resubmit, and keep documentation
These drugs require special handling, ordering, and tracking, including a special DEA form.
Schedule II controlled substances
Name 3 responsibilities of an inventory control technician.
placing orders, checking stock, returning expired meds, following order procedures, and tracking patient load
This code on the card helps route the claim to the correct processor.
PCN (Processor Control Number)
List 3 common rejection reasons.
insurance expired, drug not covered, wrong DOB, refill too soon, info mismatch
These programs help patients get access to expensive or specialty meds, often based on diagnosis.
assistance programs
Name one task a tech performs with prior authorization.
Tracking paperwork, notifying the physician, notifying the pharmacist
Name 3 types of drugs that require special handling or documentation.
controlled substances, cytotoxic drugs, investigational drugs, hazardous substances