Prescription Insurance is an important part of your job as a pharmacy technician.
You should know how to bill the companies responsible for prescription reimbursement.
You should know what to do when problems come up in the billing process.
This means knowing what some common rejections are and how to go about overriding them.
A few common ones, which will be mentioned in more detail below, are a refill too soon rejection and a prior authorization rejection.
This page will cover a number of topics, all related to prescription insurance, online adjudication rejections, and more.
The following words will be defined:
This page will also explain to you how to decipher a prescription insurance card.
Online adjudication is fast-usually taking from a few seconds to a few minutes. Sometimes problems come up during the online billing process which prevent a customer's prescription from being billed off to their insurance when they want it to be.
The most common rejection that techs receive is a refill too soon rejection.
Usually the insurance company will give the earliest date at which the refill will be covered.
When you get a refill too soon rejection when filling a new prescription, you should always look at the dose and frequency of the previous prescription.
If the prescription has changed, for instance if the frequency has increased from one tablet by mouth daily to two tablets by mouth daily, or the dose has increased from 10mg daily to 20mg daily, then you will need to get a dosage change override from the insurance company.
Sometimes getting a Dosage Change Override is as easy as putting some numbers in the Prior Auth field, and other times you are required to call the insurance company and get them to put in the override on their end.
If neither the frequency nor the dose has changed but the patient had their doctor call the prescription in because they are going away on a trip, then you will need to get a vacation override.
Like the Dosage Change Override, you will either be able to put some numbers in the PA field or another field, or you'll need to call the insurance company.
Some insurance companies have an automated line for overriding the refill too soon rejection.
They can often get your rejection overridden without even speaking to a customer service representative.
Another response could be a prior authorization rejection.
This means that the customers prescription insurance coverage requires the doctor to contact them in order for them to pay for it.
When a new customer brings in a prescription to the pharmacy, there is an intake process.
A pharmacy tech or aide will request the following information from the customer:
There are many insurance companies that you will become familiar with.
Anthem, Medco, CVS Caremark, Cigna, Express Scripts, Medicare Part D and Medicaid are a handful of the insurances you may encounter in your work as a retail pharmacy technician.
Deciphering an prescription card is easy once you know how.
All prescription cards contain a BIN number.
This number is used to identify which company reimburses the pharmacy for the medication.
Most pharmacies have a list of BIN numbers.
The acronym BIN stands for Bank Identification Number.
It is a 6 digit number which tells the pharmacy’s computer where the claim should be sent.
However, there are no longer any banks involved with the insurance billing process, so it can seem confusing.
Apparently the term was carried over from the early days of electronic banking jargon.
All prescription cards also have an ID number. Most cards have an Rx Group number as well. These are fairly self-explanatory.
It is often necessary to know the name of the person who holds the policy and the person number of the insured. Usually the individual who is the primary account holder has a person number of either "1" or "01" and the secondary (dependent-could be a spouse or child) is "2" or "02" and so on.
A co-payment is the patients’ financial responsibility. It is part of the cost of the medication that the insurance does not pay for.
Many companies have prescription drugs in different tiers.
Many companies utilize a prescription deductible. This is in addition to normal co-payments.
This means that for example, each year the customer is responsible for the first $100.00 towards the cost of his or her prescription medications.
The deductible would be an amount set by the prescription insurance company. This is in addition to their normal co-payments.
Basically, a deductible is the amount of the patients financial responsibility before their coverage kicks in.
When you or the pharmacist sends a claim online, the transmitted claim does not always go directly to your insurance company.
It goes off to a Pharmacy Benefit Manager (PBM), a company that makes its money by only handling the billing for prescriptions.
It may be a different part of the customers current insurance company, or it may be its own company, its own entity, like Express Scripts or Medco.
There are different BIN’s for each PMB.
If the company the customer works for changes PBM’s, things can get more confusing.
Their employer may have contracted with the new PBM and agreed to maintain the same benefits, but everything may not be the same when sending the claim online for billing.
The pharmacy may have a difficult time billing the claim without the prescription card. At a minimum, a pharmacy staff member needs the following from the patient's new card:
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Apr 10, 18 11:13 PM
This page covers what a Prior Authorization is and why it happens.
Apr 10, 18 10:00 PM
I know someone who is a pharmacy tech. My 10yr.olds medication was called into the pharmacy she works at. Her daughter and my daughters have an on-off
Apr 10, 18 09:26 PM
My pharmacy told my mom I didn't pick up my meds. Yes, I do have same last name but I have a different address; for all they know, that wasn't my mom.
Apr 08, 18 02:43 PM
Vitamin Resources - Information about Vitamin A, The B Vitamins, Vitamin C, and Vitamin D.
Mar 27, 18 10:20 PM
under the hippa law can a pharmacist and a pharmacy tech speak about a clients medical record amongs each other and cam pharmacy techs counsel the patient
Mar 27, 18 10:11 PM
Our pharmacy manager wants us to report any pharmacy error that happens. Why is it important to report errors? Where should we report the errors to?
Mar 27, 18 09:32 PM
We had a pharmacy tech resign, then go to work at a grocery/pharmacy - the tech has used PHI to target our patients and entice them to transfer their prescriptions.
Mar 27, 18 08:57 PM
I got my 120 Percocet Feb 18 how many should be in my bottle March 16 i take 4 a day
Mar 27, 18 08:32 PM
Is it a HIPAA violation if a pharmacist says what you are taking very loud so others can hear what you are taking?
Mar 20, 18 08:53 PM
If the name of the drug is mentioned in order to further assist the patient with getting them the medication, is this a violation of hipaa?
Mar 20, 18 08:43 PM
At 3:00 P.M., a pharmacist received an order to add 30 mEq/L of potassium chloride to the already running intravenous fluid for a patient. After checking
Mar 20, 18 08:39 PM
The USP797 rules state that no jewelry can be worn in the I.V. clean room setting because it wouldn't be sterile. I was wondering if silicone rings would
Mar 20, 18 08:38 PM
Recently there was a wrong-drug mistake at the pharmacy I'm employed at as a technician. One of my tech friends (who works at a different pharmacy) asked
Mar 20, 18 08:32 PM
I am a post surgical patient I am on liquid morphine 22ml bottle. I’m allowed to take 2ml every 3 hours how many days should by bottle last?
Mar 20, 18 08:26 PM
how many day supply is it?