1. pharm get paid! adjudication---’dealing’ with ins to get paid
max allowable cost--max price ins co will pay for generic
capitation fee- pharm gets paid x per pt per month, whether or not they come in.
deductible--ins co pays nothing until pt pays x amount for medical services. Out of pocket=you pay for it
Premium---your cost to have insurance
copayment--pt pays x amount and ins co pays rest.
Coinsurance---pt pays % of the visit
AWP--average wholesale price. found in ‘red book’. used for ins reimbursement(payment)

2. 3rd party plans
HMO health maintenance organization---providers sign contract and must follow HMO orders, wont pay outside network unless referral. prov under contract. pt must choose PCP on the list. PCP must give referral if outside network.
PPO preferred provider organization---providers contract with ppo. ins pays less if you go outside PPO.
POS point of sale---sending ins claims electronically
medicare----federal program for over 65? or disabled or kidney failure.
medicaid----federal program administered by states who determine services and entry. not all drugs paid for.
pt assistance program---drug maker offers assistance for special needs and affordability.
work comp---on the job injury. rx billed to ins co.

3. PCP= primary care physician
IPA--independent physician association
capitation-- ins pays dr per pt whether show up or not.
HMO--pt must go to PCP or IPA on list. pt pays copay.
prior authorization-(pre-auth)--no payment for x treatment or
drug until ins approves.
PPO- preferred provider organization. pt can pick dr on list or
any specialist on list. copay is higher. pt must pay deductible
before benefits kick in. dr agrees to discount to be on list.
Point of service---combo of HMO and PPO.
MMA=medicare modernization act--you get rx drug discount drug.
Medicare part A---helps pay hospice, hospital, skilled nursing
facility
Medicare part B--helps pay physican and outpatient care,
equipment (DME), chemo drugs, pays OT,PT
Medicare part C--(medicare advantge)=BUY HMO/PPO private
ins to help with medicare A and B

4. Medicare part D---(rx drug plan)= pt pays this to get discounts
meds, vaccines, supplies. problem is it pay a maximum $
then stops payment(aka donut hole). you can pay for Medigap
ins c private ins. Medicare SELECT means pt must go to
hosp/dr on list to have no fee. if you have medicare part C
then you are denied Medigap.
medicaid--poor or renal failure. fed and state pay it.
state can set requirements.
coverage is
1--pt pays nothing. 2--pay deductible 3--HMO c govt
NPI--national provider identifier- every dr and pharmacy for billing
DUR/DUE--drug utilization review. alert of dangerous drug ..or
‘fighting’ over medication for pt c ins.
DAW 0= give generic unless there is no generic made
DAW1= use brand name
DAW2= dr recommends generic, pt wants brand name
DAW3—dr wants generic, Dpharm request brand name

5. TRICARE---for military and family
CHAMPVA--- civilian health and medical program/ veteran affairs for disabled veterans and family
pt cannot have tricare and champva--pick one
show ins cards------
Premium=the cost to get your insurance
Subscriber=cardholder. Dependants on the policy. Member=1 spouse=2 id=3
Health savings account=account to pay for medical expenses.
pt drug not on formulary? dpharm calls dr to get rx changed or
dr calls ins co to get preauth for nonformulary drug. this fight
may take several days so pt can get reimbursed later or
wait for approval.
Therapeutic interchange protocol—closed formulary but will find
Therapeutic equivalent on the list.
limitation of plan exceeded---pt pays or pt can call ins co.
how do we get paid???--fill out a UCF( universal claim form)

6. somebody gotta pay markup+dispensing fee=pt cost
dispensing fee=monthly cost/rx per month
Ins co will usually pay dispensing fee
AWP+- (AWPx%)+disp fee=pt cost
Purchase order goes to vendor who makes invoice.
Verify invoice and purchase order when drugs get delivered.
Prime vendor=pharmacies main wholesaler(80-85% of needs)
with likely discount
Ins card---
BIN= 6 digits on biller ID number
PCN=processor control number
Coordination of benefits—for multiple insurance.
Secondary ins pays if primary does not pay.