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 does claim adjudication refer to in pharmacy billing?
Answer: The insurance plan's process of reviewing and determining payment for a prescription claim
Adjudication is the real-time electronic process by which an insurance plan evaluates a submitted claim and returns an approval or rejection with reimbursement details.
What is 'third-party billing' in pharmacy?
Answer: Billing an insurance company or payer on behalf of the patient
Third-party billing means the pharmacy submits a claim to the patient's insurance plan, which then reimburses the pharmacy rather than the patient paying the full amount.
What is a quantity limit (QL) restriction in pharmacy insurance?
Answer: An insurance-imposed limit on the amount of medication dispensed per fill or time period
A quantity limit restricts how much of a drug the insurer will cover (e.g., 30 tablets per 30 days) to ensure appropriate use and control costs.
What does NDC stand for, and what is it used for in pharmacy billing?
Answer: National Drug Code, a unique identifier for each drug product required on insurance claims
The NDC is an 11-digit number that uniquely identifies the manufacturer, drug, and package size, and it is submitted on every pharmacy insurance claim.
What is a 'step therapy' requirement in pharmacy insurance?
Answer: A protocol requiring patients to try a lower-cost drug before covering a higher-cost alternative
Step therapy requires a patient to try a preferred (usually generic or lower-cost) drug first, and only covers the higher-cost drug if the first option fails.
What does 'refill too soon' rejection mean in pharmacy billing?
Answer: The claim was submitted before the patient's days supply has nearly run out
A 'refill too soon' rejection means the insurance will not yet pay for a refill because the calculated days supply from the previous fill has not been used up.