Title: Perform billing and accounting functions for pharmacy functions and goods.
Course: Pharmacy Technician II (14152-II) > Section: Assisting the Pharmacist in Serving Patients

Performance should include functions such as

- auditing
- tiers
- DAW code
- day's supply
- deductible/donut hole/gap
- coupons
- personal charge accounts
- third-party rejections
- third-party reconciliations
- census maintenance
- state-managed insurance programs
- co-pay, co-insurance, dual co-pay (e.g., generic vs. brand)
- maximum allowable cost (MAC)
- usual, customary, and reasonable (UCR) price
- out-of-pocket costs

Other categories

Insurance information

- formulary
- prescription drug benefits card
  - patient ID number
  - group number
  - co-pay amount

- referrals
- prior authorization
- primary care physician
- search of insurance database for coverage
- state, federal, and third-party insurance payer
- communication of co-pay information to patient

Payment consideration

- electronic payment processing
- online adjudication
- Medication Therapy Management (MTM) billing process

Prescription Essentials

- Pharmacy Benefits Manager (PBM)
- generic and therapeutic substitution
- limits
  - quantity-per-fill
  - number of refills
  - time between refills
  - dose

- readily retrievable signature logs and prescriptions

Insurance types and providers

- Exclusive Provider Organization (EPO), Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), Health Savings Account (HSA), Point of Service Plan (POS), and Patient Centered Medical Home (PCMH)
- workers’ compensation, Consolidated Omnibus Budget Reconciliation Act (COBRA), disability insurance, and manufacturer sponsored patient assistance programs.

See PTCB 8.1, 8.2, 8.3, 8.4 (https://www.ptcb.org/lib24watch/files/pdf/169).

See ASHP 3.14 (https://www.ashp.org/-/media/assets/professional-development/technician-program-accreditation/docs/ashp-acpe-pharmacy-technician-accreditation-standard-2018.ashx?la=en&hash=36EAA6511105A6C6BFEA4F30E193892F19E2C385).

Process/Skill Questions:

- What are the steps in obtaining prior authorization? Why is each step important?
- What is the role of a pharmacy technician in processing third-party payments and/or rejections?
- What is the purpose of a financial audit?
- What is the purpose of a third-party payer audit?
- How would financial audits apply to the pharmacy setting? Why are they important?
- What are the different types of insurance plans or cards in use?
- How do the HIPAA privacy and security regulations affect billing processes involving third-party payers and vendors that process electronic payments (e.g., credit card companies, banks)?
- How would billing proceed for a patient with more than one insurance plan?
- What is the difference between primary and secondary insurance?