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