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FINANCIAL ISSUES

FINANCIAL ISSUES. CHAPTER 14. CHAPTER OUTLINE. Financial Issues Third-Party Programs private health insurance managed care programs public health insurance other programs coordination of benefits Online Adjudication Rejected Claims Other Billing Procedures Review. FINANCIAL ISSUES.

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FINANCIAL ISSUES

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  1. FINANCIAL ISSUES CHAPTER 14

  2. CHAPTER OUTLINE • Financial Issues • Third-Party Programs • private health insurance • managed care programs • public health insurance • other programs • coordination of benefits • Online Adjudication • Rejected Claims • Other Billing Procedures • Review

  3. FINANCIAL ISSUES Pharmacy Benefit Managers Computers & Third-Party Billing Co-pays

  4. THIRD PARTY PROGRAMS: PRIVATE HEALTH INSURANCE • Formularies • Managed care programs • HMOs • POS programs • PPOs

  5. THIRD-PARTY PROGRAMS:PUBLIC HEALTH INSURANCE • Medicare • Part A • Part B • Part D • Prescription drugs • Medication Therapy Management (MTM) • Medicaid

  6. OTHER THIRD-PARTY PROGRAMS • Workers Compensation • Patient Assistance Programs • Coordination of Benefits

  7. INFORMATION NEEDED FOR ONLINE CLAIM PROCESSING • cardholder identification number • group number • name of patient • birth date • gender • relationship to cardholder • date Rx is written • date Rx is dispensed • new or refill • NDC of drug • DAW indicator • amount or quantity • days supply • prescriber identification • pharmacy identification/NPI • ingredient cost • dispensing fee • total price • deductible or co-pay amount • balance due

  8. THE ONLINE PROCESS DAW INDICATORS 0 No DAW (No Dispense as Written) • DAW handwritten on the prescription by the prescriber • Patient requested brand • Pharmacist selected brand • Generic not in stock • Brand name dispensed but priced as generic • N/A • Substitution not allowed; brand mandated by law • Generic not available • Other

  9. REASONS FOR CLAIM REJECTIONS • Dependent exceeds age limit as specified by plan • Invalid birth date • Invalid person code • Invalid sex • Prescriber not a network provider • Unable to connect with insurer’s computer • Patient not covered (coverage terminated) • Refill too soon • Refills not covered • NDC not covered

  10. OTHER BILLING PROCEDURES • Paper claims • universal claim forms • In-house billing • Disease state management services • CMS-1500 form • Medication Therapy Management (MTM) services

  11. BILLING FOR MTM SERVICES • National Provider Identifier (NPI) • Current Procedural Terminology Codes (CPT codes) • Examples of online platforms • OutcomesMTM • RxTherapy Management • Mirixa

  12. MTM-BILLABLE SERVICES • Comprehensive Medication Reviews (CMR) • Prescriber consultations • cost efficiency • drug therapy problems • Patient consultations • compliance • education • monitoring

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