Pharmacy Pharmacy Billing and Insurance 2 — Questions and Answers
Question 1: What does 'coordination of benefits' mean in pharmacy billing?
- Determining which insurer pays first when a patient has multiple plans (Correct answer)
- Submitting a prior authorization request
- Reconciling a pharmacy's end-of-day claims
- Verifying a patient's eligibility for a plan
Correct answer: Determining which insurer pays first when a patient has multiple plans
Coordination of benefits (COB) is the process of determining the order in which multiple insurance plans pay for a patient's prescription to prevent overpayment.
Question 2: Which National Drug Code (NDC) segment identifies the specific package size of a medication?
- Package code (last 2 digits) (Correct answer)
- Labeler code (first 5 digits)
- Product code (middle 4 digits)
- Lot number
Correct answer: Package code (last 2 digits)
The NDC is an 11-digit code in 5-4-2 format; the last 2-digit segment is the package code identifying the package type and size.
Question 3: A pharmacy submits a claim and receives an 'eligibility not found' rejection. What is the most likely first step?
- Verify the patient's insurance ID, group number, and date of birth (Correct answer)
- Call the prescriber to reissue the prescription
- Dispense the medication and bill the patient in full
- Submit the claim to Medicaid instead
Correct answer: Verify the patient's insurance ID, group number, and date of birth
An eligibility rejection typically results from a data entry error, so verifying and correcting the patient's insurance information is the appropriate first step.
Question 4: What is the purpose of a prior authorization (PA) in pharmacy?
- To obtain insurer approval before dispensing a non-formulary or restricted drug (Correct answer)
- To allow a patient to pick up a refill early
- To transfer a prescription from another pharmacy
- To override a refill-too-soon rejection
Correct answer: To obtain insurer approval before dispensing a non-formulary or restricted drug
A prior authorization requires the prescriber to submit clinical justification to the insurance plan before the plan will cover a specific medication.
Question 5: Which claim field is used to report the prescriber's NPI number?
- NCPDP field 411-DB (Prescriber ID) (Correct answer)
- NCPDP field 444-E9
- NCPDP field 202-B2
- NCPDP field 301-C1
Correct answer: NCPDP field 411-DB (Prescriber ID)
The prescriber's NPI is reported using NCPDP field 411-DB along with a qualifier indicating the NPI identifier type.
Question 6: A drug is classified as Tier 3 on a formulary. What does this typically mean for the patient?
- Higher co-pay, usually for non-preferred brand drugs (Correct answer)
- Lowest co-pay, generic drugs
- Specialty drugs requiring special handling
- Drug is not covered at all
Correct answer: Higher co-pay, usually for non-preferred brand drugs
Tier 3 on most insurance formularies represents non-preferred brand-name drugs that carry a higher co-pay than preferred generics or preferred brands.
Pharmacy Pharmacy Billing and Insurance 2
What does 'coordination of benefits' mean in pharmacy billing?