Prior authorization, rejected claim codes, and third-party billing workflow concepts tested on the PTCB exam.
35 cards · basic cards · AI-written, checked twice. Edit anything.
- PA (pharmacy billing)
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Prior Authorization- What is prior authorization?
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Insurer approval required before a specific medication will be covered- Who typically initiates a prior authorization request?
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The prescriber's office- What is a common reason an insurer requires prior authorization?
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The drug is non-formulary or high-cost- What is step therapy?
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A requirement to try a lower-cost drug first before a more expensive one is covered- What is a formulary?
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A list of drugs a health plan covers- BIN (claims billing)
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Bank Identification Number- What is the purpose of the BIN number on an insurance card?
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Routes the claim to the correct claims processor- What does PCN stand for on an insurance card?
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Processor Control Number- What is the purpose of the group number on an insurance card?
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Identifies the specific employer or plan group- What is the cardholder ID (member ID) used for?
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Identifies the specific insured individual on a claim- NCPDP
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National Council for Prescription Drug Programs- What does NCPDP reject code 75 mean?
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Prior Authorization Required- What does NCPDP reject code 70 mean?
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Product/Service Not Covered- What does NCPDP reject code 76 mean?
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Plan Limitations Exceeded
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