PTCE Billing and Reimbursement Flashcards
6 cards from real PTCE practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 PTCE Billing and Reimbursement flashcards as text
What is the 'usual and customary' (U&C) price in pharmacy billing?
Answer: The price a pharmacy charges cash-paying customers
The U&C price is the standard cash price a pharmacy charges, and insurance plans typically reimburse the lower of the U&C or contracted rate.
What does 'days supply' mean in the context of a prescription claim?
Answer: The number of days the dispensed quantity is expected to last
Days supply is calculated by dividing the dispensed quantity by the daily dose and is required on insurance claims to prevent early refills.
What does co-insurance mean in pharmacy benefits?
Answer: A percentage of the drug cost the patient pays after meeting the deductible
Co-insurance is the patient's percentage share of the drug cost (e.g., 20%) after their deductible has been met, as opposed to a fixed copay.
What does claim rejection code '75' typically indicate?
Answer: Prior authorization required
Rejection code 75 means the insurance requires a prior authorization before it will reimburse for the prescribed medication.
What is a drug formulary tier system used for?
Answer: Determining the patient's copay level based on drug category
Formulary tiers assign drugs to categories (e.g., generics, preferred brands, non-preferred brands) with increasing copay amounts at higher tiers.
What is a pharmacy deductible?
Answer: The amount a patient must pay out-of-pocket before insurance begins covering prescriptions
A deductible is the set amount a patient must spend on covered medications before the insurance plan starts paying its share.