Podcast
Questions and Answers
What is the main purpose of claims adjudication?
What is the main purpose of claims adjudication?
- To fill prescriptions for patients
- To provide patients with prescription medications
- To collect patient payments at the pharmacy
- To evaluate a medical claim submitted to insurance (correct)
Which of the following is NOT typically an outcome of claims adjudication?
Which of the following is NOT typically an outcome of claims adjudication?
- Accepted
- Pending Review
- Approved (correct)
- Denied/Declined
What does the Rx BIN on a prescription insurance card do?
What does the Rx BIN on a prescription insurance card do?
- Narrows a claim to the specific insurance plan
- Identifies the insured individual
- Routes a claim toward the correct insurance (correct)
- Counters fraud in prescription claims
During which step of the prescription pathway does the pharmacist verify prescription accuracy?
During which step of the prescription pathway does the pharmacist verify prescription accuracy?
What is a potential reason for the NCPDP reject code 50?
What is a potential reason for the NCPDP reject code 50?
Which Medicare part is primarily used to bill for specific prescription items?
Which Medicare part is primarily used to bill for specific prescription items?
Which of the following is an example of a Medicare Part B coverage?
Which of the following is an example of a Medicare Part B coverage?
What happens in the 'Filling' step of the prescription pathway?
What happens in the 'Filling' step of the prescription pathway?
Why is it important for patients to present their prescription insurance card?
Why is it important for patients to present their prescription insurance card?
What role do pharmacy technicians play during the input stage of the prescription pathway?
What role do pharmacy technicians play during the input stage of the prescription pathway?
What is a plan exclusion in an insurance policy?
What is a plan exclusion in an insurance policy?
Which of the following medications are often excluded as a class from insurance coverage?
Which of the following medications are often excluded as a class from insurance coverage?
What does prior authorization (PA) require from a health plan?
What does prior authorization (PA) require from a health plan?
What typically happens when a prescription's quantity exceeds the plan limit?
What typically happens when a prescription's quantity exceeds the plan limit?
What is a common reason for a Drug Utilization Review (DUR) rejection?
What is a common reason for a Drug Utilization Review (DUR) rejection?
What must pharmacists do when they encounter clinical alerts during prescription verification?
What must pharmacists do when they encounter clinical alerts during prescription verification?
When could a patient receive a 'Refill Too Soon' rejection?
When could a patient receive a 'Refill Too Soon' rejection?
What are clinical alerts/warnings typically triggered by?
What are clinical alerts/warnings typically triggered by?
What could happen if the cost of a prescription exceeds the maximum set by the insurance?
What could happen if the cost of a prescription exceeds the maximum set by the insurance?
What is a common reason for a clinical alert regarding a drug-drug interaction?
What is a common reason for a clinical alert regarding a drug-drug interaction?
Flashcards
Claims Adjudication
Claims Adjudication
The process where an insurance company evaluates a medical claim.
Auto-adjudication
Auto-adjudication
Claims are submitted electronically and reviewed by software for errors and eligibility.
Member ID
Member ID
A unique number identifying an insured individual for insurance purposes.
Rx BIN
Rx BIN
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Rx PCN
Rx PCN
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Rx Group
Rx Group
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NCPDP Reject Code 50
NCPDP Reject Code 50
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Medicare Part B
Medicare Part B
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Prescription Pathway
Prescription Pathway
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Claims Denials
Claims Denials
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Plan Exclusion
Plan Exclusion
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Insurance Formulary
Insurance Formulary
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Prior Authorization (PA)
Prior Authorization (PA)
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Drug Utilization Review (DUR)
Drug Utilization Review (DUR)
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Plan Limit
Plan Limit
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Cost Exceeds Maximum
Cost Exceeds Maximum
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Refilling Too Soon
Refilling Too Soon
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Clinical Alert
Clinical Alert
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Drug-drug interaction
Drug-drug interaction
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Duplicate Therapy
Duplicate Therapy
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Study Notes
Claims Adjudication
- Claims adjudication is the payer's (insurance company's) process for evaluating medical claims.
- Claims are often submitted electronically via auto-adjudication.
- Auto-adjudication involves software automatically checking claims for errors and eligibility, then returning a payment amount.
- Possible outcomes include acceptance or denial/declined claims.
Insurance Cards
- Member ID: A unique number identifying the insured individual.
- Rx BIN (Bank Identification Number): Routes claims to the correct insurance company.
- Rx PCN (Processor Control Number): Details the specific insurance plan within a company.
- Rx Group: Identifies the associated employer plan.
- Important Tip: Prescription insurance cards are often required, as medical cards might lack necessary information.
- Medicare Part B: Handles prescription items not usually covered by other Medicare parts; often called the "Red, White, and Blue Card".
- Medicare Part B Coverage Examples: Vaccines (flu, pneumonia, Hepatitis B, COVID-19). Diabetes testing supplies. Transplant drugs to suppress the immune system. Oral chemotherapy.
Prescription Pathway
- Step 1: Patient submits prescription.
- Step 2: Pharmacy technician enters prescription information.
- Step 3: Pharmacist verifies prescription input.
- Step 4: Pharmacy submits claim to insurance electronically.
- Step 5: Pharmacy fills the prescription based on the claim outcome.
- Step 6: Pharmacist double-checks the filled prescription.
Common NCPDP Reject Codes
- 50 - Non-Matched Pharmacy Number: Rejection when the insurance isn't contracted with the pharmacy ("out-of-network"). Also for specialty drugs at non-specialty pharmacies.
- 70 - Plan Exclusion: Insurance policy excludes coverage for certain drugs. Does not factor toward out-of-pocket maximum for the excluded drug. This means the drug isn't on the insurance formulary. Common examples for this include weight-loss agents.
- 75 - Prior Authorization Required: Health plan requires approval for a medication before it is covered. Often needed for tier 2+ formulary medications. Formulary is a list of covered drugs, often tiered for cost and coverage levels.
- 76 - Plan Limitations Exceeded: Insurance plan has a limit on quantity of certain drugs covered within a time frame; common for medications with strict dosing guidelines.
- 78 - Cost Exceeds Maximum: Prescription cost exceeds a set insurance limit. May require a Prior Authorization or switching to a more affordable drug. Resolutions involve verifying claim processing accuracy and potentially discussing a lower cost alternative medication with the provider.
- 79 - Refill Too Soon: Rejection for refills before the insurance allows it; the rejection gives the earliest eligible refill date. Pharmacists can sometimes override this, in consultation with insurance if needed.
- 88 - Drug Utilization Review (DUR): Rejection requiring clinical pharmacist knowledge. Reasons for DUR rejection include duplicate therapy, overuse, drug-drug interactions, and drug-pregnancy interactions. Requires a comprehensive assessment of the patient's medications to ensure safety.
Clinical Alerts and Warnings
- Clinical alerts appear in pharmacy management systems during prescription verification, spotting potential safety concerns.
- Pharmacists use professional judgment to override alerts when appropriate.
- Example Alerts: Allergy alerts, drug-drug interaction alerts, duplicate therapy alerts, excessive dose alerts, high-risk medication alerts, pediatric dosing concerns, and Beers criteria warnings for older adults.
Case Examples
- Case #1: Allie Gator's prescription triggered a "75 Prior Authorization Required" rejection.
- Case #2: Johnny Rose's prescription prompted an "Allergy (Codeine)" clinical alert due to documented allergy.
- Case #3: Ryan Reynolds' prescription produced a "Drug Utilization Review (DUR)" and "Drug-Drug Interaction" clinical alert.
Key Takeaways for Pharmacists
- Responding to Alerts: Develop a systematic approach for evaluating and addressing clinical alerts, documenting actions taken.
- Patient Communication: Explain rejections and clinical alerts to patients clearly.
- Provider Communication: Communicate with prescribers effectively on prior authorizations, alternative therapies, and DUR resolution
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