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A comprehensive set of questions and answers covering key aspects of the ptcb exam, focusing on pharmacy billing codes, prior authorization procedures, claim rejection troubleshooting, coordination of benefits, and relevant legislation. it's a valuable resource for pharmacy students and professionals preparing for the ptcb exam or seeking to enhance their knowledge of pharmacy regulations and billing practices. The q&a format facilitates effective learning and knowledge retention.
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ANS Medication Therapy Manage- ment (MTM)
ANS Incident-to
ANS Transitional care management (TCM)
ANS CMS annual wellness visit (AWV)
ANS Incident-to physician Chronic care management
ANS ncident-to physician Complex chronic care management
ANS Diabetes self-management training
ANS Diabetes education
ANS Office visit in a hospital-based clinic (Hospital outpatient)
ANS The majority of options for pharmacist revenue generation are through the Evaluation and Management (E&M)
ANS the need to obtain permission from the insurance com- pany before seeking certain types of services
1- A brand name medication that is available as a generic
wrinkle treatment)
medication that treats non-life threatening conditions 6- A medication not usually covered by the insurance company, but deemed medically necessary by the physician
Step 1 The pharmacy contacts the physician who prescribed the medication to see if he or she obtained prior authorization from the insurance company when the drug was prescribed. Step 2
insurance card or insurance company and then edit the claim before resubmitting. You may need to contact the insurance company to get more information on the problem.
group number on the insurance card, fix the error, and resubmit the claim.
must have a contract with the payer. Once the contract is negotiated, the payer will provide an NPI number. This number is then inputted into the pharmacy software and included on all claims.
this, you must find the correct Cardholder ID number and resubmit the claim.
coverage because of the medication expense, it may be rejected. Additionally, if the medication was already filled in the last 30 days or the quantity dispensed is over the allowed amount for the day supply, the claim may be rejected. To fix these issues, you will need to contact the insurance company to obtain an override or approval on the cost before resubmitting the claim.
from time of service to file a claim. When claims are filed past that time, the claim may be rejected.
rejection. Common errors include incorrect name, days supply, provider, date of birth, etc.
employer-provided insurance, the patient's coverage may not be current.
amount of coverage they provide for each patient annually or for a lifetime. The claim may be rejected if the coverage limits have been exceeded.
when it either is not refillable or within too short of a time frame. The insurance payer may reject this claim.
medication. Most insurance companies cover only a 30-day supply of medication. Mail- order prescriptions may cover a 90-day supply. The amount depends on the actual drug.
ANS is the process in which two or more health insurers cover the same person(s) but limit the total benefit payable for a claim to an amount not exceeding the total cost of the claim. Coordination of Benefits applies to retail pharmacy claims, member- submitted paper claims, and mail-order claims.
If the court decree states that the parents have joint custody without specifying that one parent has healthcare coverage responsibility, the Birthday Rule determines the ordre of benefits. If there is no court decree allocating healthcare coverage responsibility for the child, the order of benefits for the child is as follows ANS a. the plan covering the custodial parent; b. the plan covering the custodial parent's spouse; c. the plan covering non-custodial parent; and then, d. the plan covering the noncustodial parent's spouse
ANS 24 hours in hospitals pharmacy and at least 30 min prior to use in comunity pharmacy.
ANS work should be at least 6 inches into the hood.
ANS Class 100 (ISO 5)
ANS prohibited instersate commerce and adulterated and misbranded drugs.
ANS Established the FDA (stated the drugs cannot brought on the market untill proved to be safe), clarified the definition of misbranding and adulteration.
ANS It requires the drug prove to be safe and print instructions clearly on the manufacture label. Created new legend drug what's known as prescription drug. And created warning (Caution Federal law prohibits dispensing without prescription) Currently the requirement has been changed in shorter warning (Rx only).
ANS This law requres for the first time a proof of the effectiveness of the drug as well as its safety.
ANS This act simplifies many FSA regulations and procedures. It allows greater ease and speed with the FDA can approve a new drug and granted access to investigational medication. It's also abbreviated the warning to Rx Only
ANS This act permitted physician who completed a training course and who registers with the DEA to prescribe approved C-III, C-IV, C-V medication.
ANS Allow medicaire benificiaries to enroll in medicaire advantage, or medicaire part D (coverage for prescription drug).
ANS Expands Harrison Act to include barbiturates and stimulant drugs
ANS The Harrison Act and DACA were combined under newly formed Bureau of Narcotics and Dan- gerous Drugs. in 1973, the Bureau was renamed to the DEA (Drug Enforcement Administration).
ANS - Known as Controlled Substances Act (CSA). Replaced the Harrison and DACA and established the concept of the DEA number originated with the CSA.
ANS Requires locking cap on all prescriptions dispensed from pharmacy with only 3 exceptions.
Also required all the prescriptions bottles to be child proof.
ANS 1) Retro- spective Drug Utilization Review (DUR)
patients)
ANS Non-government organization conduct voluntary certification and inspec- tion on 20,000+ healthcare organizations including Hospital, Nursing Homes, long term care facilites, Ambulatory care providors, and clinical laboratories
ANS 1) Regulated by FDA
ANS 1) Ensures safe workplace for employee by reducing hazards in workplace
illness
Health consequences are reversible Class 3 Not likely to cause adverse health consequences (physically adulterated drug or mislabelling drugs)
ANS Phase I - Trial involves small # of volunteers to determine maximum tolerated dose of applicant drug (toxicity) Phase II - Primarily concerned with (effectiveness) Phase III - Last trial before NDA submitted to FDA. "Double Blind" method with thousands of individuals. Phase IV - takes place after NDA submits to FDA. Allows manufactures to produce drugs
ANS Each drug produced by a manufacturer is iden- tified with a specific NDC number. The NDC number is composed of three sets of numbers, which identifies the manufacturer, drug, and pack size. The first 5 numbers represent the manufacturer. the second 4 numbers represent the drug. The last/third 2 numbers represent the packaging size. 00000-0000-
ANS (1st + 3rd + 5th) + 2 (2nd + 4th + 6th) = last digit is last digit of DEA #. Usually the first letter is
A or B for physician, provider F or P for manufacturer M for mid-level provider The 2nd letter represents the last name of the provider AG
ANS 222 - to order CII's 224 - to register with the DEA - check box to get 222 forms with registration 106 - to report theft or loss to the DEA 41 - to report drugs surrendered for disposal 104 - pharmacist surrender his/her license
ANS classifies controlled substances accord- ing to their abuse potentials. Schedule II = Prescription can be handwritten or computer generated but must be signed in ink by physician (no allowable refill) Schedule III-V = Prescription can be handwritten or computer generated must be signed by physician in ink the office may telephone or fax prescription. Paitent may receive up to 5 refills within 6 months.
ANS 1 oz = 28.4 g
ANS 1 qt = 946 mL
ANS 1 qt = 2 pt
ANS 1w/v1000 = (g of active ingredient/mL of active ingredient)
ANS Insured
ANS Spouse
ANS Dependent
ANS Day supplied missing or not valid
ANS Relationship code invalid or missing
ANS When date of birth invalid or missing
ANS Processor Control Number (PCN)
ANS Ampul require the suse of filter needle to remove very samll particles of glass that may have fallen into the liquid when the ampule was broken.
ANS vertical laminar flow hood accord- ing to USP <797>
ANS prohibts artificial nails , cosmatics, and jewlery
ANS counter balance
ANS DOT , department of Transportaion
ANS physician name not re- quired on label , but beyond -use date, deip rate and ingredients are required on the IV label.
ANS Class A
ANS every 12 months , according to USP<795>
provide ANS ISO 5 (formaly class 100 area)
ANS lumen