Performance should include functions such as
- auditing
- tiers
- DAW code
- day's supply
- deductible/donut hole/gap
- coupons
- personal charge accounts
- third-party rejections
- third-party reconciliations
- census maintenance
- state-managed insurance programs
- co-pay, co-insurance, dual co-pay (e.g., generic vs. brand)
- maximum allowable cost (MAC)
- usual, customary, and reasonable (UCR) price
- out-of-pocket costs
Other categories
Insurance information
- formulary
- prescription drug benefits card
- patient ID number
- group number
- co-pay amount
- referrals
- prior authorization
- primary care physician
- search of insurance database for coverage
- state, federal, and third-party insurance payer
- communication of co-pay information to patient
Payment consideration
- electronic payment processing
- online adjudication
- Medication Therapy Management (MTM) billing process
Prescription Essentials
- Pharmacy Benefits Manager (PBM)
- generic and therapeutic substitution
- limits
- quantity-per-fill
- number of refills
- time between refills
- dose
- readily retrievable signature logs and prescriptions
Insurance types and providers
- Exclusive Provider Organization (EPO), Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), Health Savings Account (HSA), Point of Service Plan (POS), and Patient Centered Medical Home (PCMH)
- workers’ compensation, Consolidated Omnibus Budget Reconciliation Act (COBRA), disability insurance, and manufacturer sponsored patient assistance programs
- Hospice
See ASHP 3.14.
Process/Skill Questions:
- What are the steps in obtaining prior authorization? Why is each step important?
- What is the role of a pharmacy technician in processing third-party payments and/or rejections?
- What is the purpose of a financial audit?
- What is the purpose of a third-party payer audit?
- How would financial audits apply to the pharmacy setting? Why are they important?
- What are the different types of insurance plans or cards in use?
- How do the HIPAA privacy and security regulations affect billing processes involving third-party payers and vendors that process electronic payments (e.g., credit card companies, banks)?
- How would billing proceed for a patient with more than one insurance plan?
- What is the difference between primary and secondary insurance?