| abuse | action that misuses money that the government has allocated
|
 |
|
|
| account reconciliation | the act of comparing the total charges and amount owed with the reimbursement received from the insurer and the patient
|
|
|
|
| accounts receivable (AR) | remaining balance due after an initial payment has been made
|
|
|
|
| adjudication | payer’s processing of claim data to decide whether a drug is covered by the patient’s plan and properly utilized
|
|
|
|
| administrative edits | checks that typically indicate that additional information is required to process the claim or that some information has been entered incorrectly
|
|
|
|
| advance beneficiary notice (ABN) of noncoverage | form given to a patient before treatment when a provider thinks that Medicare will deem a procedure not reasonable and necessary and will not cover it
|
|
|
|
| aging reports | documents used to identify patient accounts with overdue outstanding balances
|
|
|
|
| any willing provider | state laws requiring pharmacy benefit managers to contract with any pharmacy willing to accept their reimbursement rates
|
|
|
|
| ASC X12N 835 Pharmacy Remittance Advice Template | the HIPAA-compliant standard format used for transmitting remittances electronically
|
|
|
|
| audit | methodical examination of selected pharmacy records
|
|
|
|
| authorization | document a patient must sign for a covered entity to use or disclose information other than for TPO
|
|
|
|
| average wholesale price (AWP) | the average price at which a wholesaler sells prescription drugs to pharmacies, physicians, and other consumers
|
|
|
|
| benefits | payments made by a health plan for medical services
|
|
|
|
| billing cycle | ten-step work flow followed at a pharmacy to care for patients’ financial matters
|
|
|
|
| birthday rule | a rule for determining a child’s primary insurance based on the parent whose date of birth is earlier in the calendar year
|
|
|
|
| business associates | in HIPAA terms, agencies that must comply with the law in order to do business with covered entities
|
|
|
|
| capitation | fee usually paid monthly by a patient to the primary care physician regardless of the number of times the patient visits the physician
|
|
|
|
| catastrophic cap | limit on the total medical expenses a patient must pay in one year
|
|
|
|
| categorically needy | special group of Medicaid recipients whose needs are addressed under the Welfare Reform Act
|
|
|
|
| Centers for Medicare and Medicaid Services (CMS) | main federal government agency responsible for health care
|
|
|
|
| CHAMPVA | program that helps pay health care costs for families of veterans who are totally and permanently disabled because of service-related injuries
|
|
|
|
| Claim Adjustment Group Codes | codes that describes the type of needed claim adjustment
|
|
|
|
| Claim Adjustment Reason Codes (CARC) | mandatory codes used to specify reasons for adjustments to claims
|
|
|
|
| clearinghouses | companies that help providers handle electronic transactions such as pharmacy claims
|
|
|
|
| closed formulary | type of formulary that will not provide coverage for unlisted drugs without an authorized medical exception from a physician
|
|
|
|
| CMS-1500 | the prescribed paper form for health care claims prepared and submitted by physicians and suppliers
|
|
|
|
| code set | any group of codes used for encoding data elements
|
|
|
|
| coinsurance | percentage of the fees owed by the policyholder
|
|
|
|
| compliance plans | plans a pharmacy practice writes and implements to uncover compliance problems and correct them to avoid risking liability
|
|
|
|
| compounded medications | medications containing one or more ingredients that are prepared on-site by a pharmacist
|
|
|
|
| compounding | the preparation or mixing of combinations of drugs prior to purchase
|
|
|
|
| consumer-driven health plan (CDHP) | type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses
|
|
|
|
| coordination of benefits (COB) | a provision ensuring that maximum appropriate benefits are paid to a patient covered under more than one policy without duplication
|
|
|
|
| copayment | small fixed fee paid by a patient for a drug
|
|
|
|
| corporate integrity agreement | compliance action under which a provider’s Medicare billing is monitored by the Office of the Inspector General
|
|
|
|
| coverage gap | point where a patient and the Medicare drug plan have spent a predetermined amount of money for covered drugs and the patient is responsible for the entire cost of the drugs
|
|
|
|
| covered entities | organizations that electronically transmit any information that is protected under HIPAA
|
|
|
|
| covered expenses | expenses incurred by or on behalf of a covered person for supplies that are ordered by a doctor, are medically necessary, and are not excluded by any provision of the policy
|
|
|
|
| crossover claim | claims submitted first to Medicare and then to Medicaid
|
|
|
|
| Current Procedural Terminology (CPT) | mandated code set for physician procedures and services under TCS
|
|
|
|
| deductible | amount paid by a policyholder each year before benefits from a health plan will start
|
|
|
|
| Defense Enrollment Eligibility Reporting System (DEERS) | worldwide database of people covered by TRICARE
|
|
|
|
| de-identified health information | health information that neither identifies nor provides a reasonable basis to identify an individual
|
|
|
|
| designated record set (DRS) | medication and billing records a pharmacy maintains
|
|
|
|
| desk audits | computerized audits performed off-site
|
|
|
|
| diagnostic services | treatment for a patient who has been diagnosed with a condition or with a high probability for it
|
|
|
|
| discount card | offered by states to people who cannot afford prescription drugs
|
|
|
|
| disease management (DM) programs | programs that are often provided by pharmacy benefit managers for common and potentially high-cost conditions such as asthma, diabetes, heart disease, and depression
|
|
|
|
| dispense as written (DAW) codes | a set of NCPDP codes used to inform third parties of the reason for filling a prescription with a brand or generic product
|
|
|
|
| dispensing fee | the fee for a pharmacy’s professional services
|
|
|
|
| drug utilization review | tool used to ensure safety, improve care quality, and promote compliance with the formulary
|
|
|
|
| durable medical equipment (DME) | certain medical equipment that is ordered by a doctor for use in the home
|
|
|
|
| Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) | prevention, early detection, and treatment program for children under the age of twenty-one who are enrolled in Medicaid
|
|
|
|
| EDI (electronic data interchange) | claims that are sent electronically between the pharmacy management system and the payer
|
|
|
|
| edits | checks that evaluate prescription claims for errors and missing information, and that ensure compliance with the benefit plan and industry standards
|
|
|
|
| electronic prescribing (eRx) | use of software by a physician to transmit an order
|
|
|
|
| encryption | process of encoding information in such a way that only the person or computer with the key can decode it
|
|
|
|
| explanation of benefits (EOB) | document that comes to a pharmacy showing the details for a claim (also known as a remittance advice)
|
|
|
|
| family deductible | deductible that can be met by the combined payments to providers for any covered members of the insured’s family
|
|
|
|
| Federal Medicaid Assistance Percentage (FMAP) | payments made by the federal government based on a state’s average per capita income in relation to the national income average
|
|
|
|
| field audits | audits that are performed on-site at the pharmacy
|
|
|
|
| fiscal agent | organization that processes claims for a government program
|
|
|
|
| formulary | list containing the Food and Drug Administration (FDA)-approved brand-name and generic medications a plan covers (also known as a preferred drug list or prescription drug list)
|
|
|
|
| fraud | act of deception used to take advantage of another person
|
|
|
|
| group health plan (GHP) | medical insurance coverage that employers buy from insurance companies for their employees
|
|
|
|
| Healthcare Common Procedure Coding System (HCPCS) | mandated code set for reporting supplies, orthotic and prosthetic devices, and durable medical equipment under TCS
|
|
|
|
| Health Care Fraud and Abuse Control Program | program created to uncover and prosecute fraud and abuse
|
|
|
|
| Health Insurance Portability and Accountability Act (HIPAA) of 1996 | law designed to protect people’s private health information, ensure health coverage for workers and their families when they change or lose jobs, and uncover fraud and abuse
|
|
|
|
| health maintenance organization (HMO) | type of managed care organization where patients pay fixed premiums and very small (or no) copayments when they need services
|
|
|
|
| health plan | organization that offers financial protection in case of illness or accidental injury (also known as insurance payer)
|
|
|
|
| HIPAA Electronic Health Care Transactions and Code Sets (TCS) | code sets that make it possible for providers and health plans to exchange data using a standard format and standard code sets
|
|
|
|
| HIPAA National Identifiers | numbers of predetermined length and structure used for identification purposes
|
|
|
|
| HIPAA Privacy Rule | the first comprehensive federal protection for the privacy of health information
|
|
|
|
| HIPAA Security Rule | rule that requires covered entities to establish safeguards to protect a patient’s protected health information
|
|
|
|
| hospice | public or private organization that provides services for terminally ill patients and their families
|
|
|
|
| ICD-9-CM | mandated code set for diagnoses under TCS
|
|
|
|
| individual deductible | deductible that must be met for each individual—whether the policyholder or a covered dependent—who has an encounter
|
|
|
|
| individual health plan (IHP) | medical insurance plan purchased by an individual
|
|
|
|
| initial preventive physical examination (IPPE) | once-in-a-lifetime benefit under Medicare Part B that must be received in the first six months after the date of enrollment
|
|
|
|
| insurance payers | organizations that offer financial protection in case of illness or accidental injury (also known as health plans)
|
|
|
|
| limiting charge | maximum amount a nonPar provider can charge a Medicare patient based on the Medicare nonparticipating fee schedule
|
|
|
|
| managed care | method of supervising medical care with the goal of ensuring that patients get needed services in the most appropriate, cost-effective setting
|
|
|
|
| managed care organization (MCO) | plan that establishes links among provider, patient, and payer by combining the delivery of services with the financing and management of health care
|
|
|
|
| maximum allowable cost (MAC) | the greatest unit price that the payer or pharmacy benefit manager will pay
|
|
|
|
| maximum benefit limit | monetary amount after which a plan’s benefits end
|
|
|
|
| Medicaid | assistance program that pays for health care services for people with incomes below the national poverty level
|
|
|
|
| medical insurance | agreement between a person and a health plan that enables individuals to be able to afford medical expenses
|
|
|
|
| medically indigent/needy | individuals who earn enough money to pay for basic living expenses but cannot afford high medical bills
|
|
|
|
| medically necessary | insurance term referring to appropriate medical treatment given under generally accepted standards of medical practice
|
|
|
|
| medical records | patient’s medication files and other clinical materials that are legal documents belonging to the pharmacy that created them
|
|
|
|
| medical savings account (MSA) | program that combines a high-deductible fee-for-service plan with a tax-exempt trust to pay for qualified medical expenses
|
|
|
|
| Medicare | federal health insurance program for people who are sixty-five and older and some people with disabilities and end-stage renal disease (ESRD)
|
|
|
|
| Medicare administrative contractors (MACs) | insurance organizations the federal government contracts with to pay Medicare claims on its behalf
|
|
|
|
| Medicare Advantage | new name for Medicare 1 Choice plans, with some changed rules to give Part C enrollees better benefits and lower costs
|
|
|
|
| Medicare beneficiary | person covered by Medicare
|
|
|
|
| Medicare Fee Schedule (MFS) | basis for payments for all Original Medicare Plan services
|
|
|
|
| Medicare Part A | program that helps pay for inpatient hospital services, care in skilled nursing facilities, home health care, and hospice care
|
|
|
|
| Medicare Part B | program that helps pay for physician services, outpatient hospital services, durable medical equipment, and other services and supplies
|
|
|
|
| Medicare Part C | program that enables private health insurance companies to contract with CMS to offer Medicare benefits through their own policies
|
|
|
|
| Medicare Part D | program that provides voluntary Medicare prescription drug plans to people who are eligible for Medicare
|
|
|
|
| Medicare Remittance Notice (MRN) | notice sent to an office to show the amount of a patient’s medical bills that has been applied to the annual deductible
|
|
|
|
| Medicare Summary Notice (MSN) | notice sent to a patient to show the amount of his or her medical bills that has been applied to the annual deductible
|
|
|
|
| medication therapy management (MTM) | provision of the Medicare Part D prescription drug plan that offers pharmacists free education to improve medication use and reduce the number of adverse drug events
|
|
|
|
| Medigap insurance | policies from federally approved private insurance carriers to fill gaps in Medicare coverage
|
|
|
|
| Medi-Medi beneficiary | individuals who are eligible for both Medicaid and Medicare
|
|
|
|
| member pharmacy | pharmacy that falls within the network created by a managed care organization
|
|
|
|
| military treatment facility (MTF) | military-operated medical facility
|
|
|
|
| minimum necessary standard | precautions a covered entity must take to limit the usage of protected health information by taking reasonable safeguards to protect it from incidental disclosure
|
|
|
|
| National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version 5.1 and Batch Standard 1.1 | the HIPAA standard for electronic retail pharmacy drug claims
|
|
|
|
| National Drug Code (NDC) | an eleven-digit code assigned to all prescription drug products by the labeler or distributor of the product under FDA regulations
|
|
|
|
| National Provider Identifier (NPI) | standard for the identification of providers when filing claims and other transactions
|
|
|
|
| NCPDP Provider Identification Number | provides pharmacies with a unique national identifier for use in interactions with payers and claim processors
|
|
|
|
| network | group of participating providers, including physicians, hospitals, and pharmacies, created by a managed care organization for its policyholders
|
|
|
|
| noncovered (excluded) services | services that a medical insurance policy does not pay for
|
|
|
|
| Notice of Privacy Practices (NPP) | document explaining how patients’ protected health information may be used and describing their rights
|
|
|
|
| Office for Civil Rights (OCR) | enforcer of HIPAA privacy regulations
|
|
|
|
| Office of the Inspector General (OIG) | detects health care fraud and abuse and enforces all laws relating to them
|
|
|
|
| open enrollment period | specific periods of time when employees choose a particular set of benefits for the coming benefit period
|
|
|
|
| open formulary | least restrictive type of formulary, which will sometimes cover medications that are not listed
|
|
|
|
| Original Medicare Plan | term used by Medicare to refer to its fee-for-service plan
|
|
|
|
| out-of-network | term for physicians, hospitals, and pharmacies that are not part of the network created by a managed care organization for its policyholders
|
|
|
|
| out-of-pocket expenses | amounts that a patient pays for medical expenses
|
|
|
|
| password | key to information for individuals who have been granted access rights
|
|
|
|
| payer of last resort | term for Medicaid, which pays after all other insurance carriers
|
|
|
|
| pharmacy benefit | feature of a policy that provides coverage for selection of prescription medications
|
|
|
|
| pharmacy benefit manager (PBM) | third-party administrator of prescription drug programs that processes and pays prescription drug claims
|
|
|
|
| pharmacy claim | information transmitted to a payer that identifies the policyholder, the prescriber, the pharmacy sending the claim, and the medications being supplied
|
|
|
|
| pharmacy management (PM) system | system that stores, processes, transmits, and receives billing data
|
|
|
|
| pharmacy technician insurance specialist | job title that describes the vital job of getting paid for prescriptions, whether the setting is a large pharmacy practice where individuals specialize in various tasks or a small practice where the same individual may handle this role as well as others, such as filling prescriptions
|
|
|
|
| point of sale (POS) | drug plan benefits received at the time the pharmacy technician insurance specialist processes a person’s prescriptions
|
|
|
|
| policyholder | individual who enters into an agreement with a health plan to receive medical insurance
|
|
|
|
| preferred drug list | list containing the Food and Drug Administration (FDA)-approved brand-name and generic medications a plan covers (also known as a formulary or prescription drug list)
|
|
|
|
| preferred provider organization (PPO) | most popular type of managed care organization that combines flexibility in patients’ choice of physicians with reduced costs for medical services
|
|
|
|
| premium | fee paid monthly to a health plan by a person who buys medical insurance
|
|
|
|
| prescription drug deductible amount | term used to refer to a deductible in prescription benefit plans
|
|
|
|
| prescription drug list (PDL) | list containing the Food and Drug Administration (FDA)-approved brand-name and generic medications a plan covers (also known as a formulary or preferred drug list)
|
|
|
|
| Prescription Drug Plan (PDP) | basic Medicare option for offering prescription drug coverage
|
|
|
|
| prescription legend drug | medication whose label is required to bear the legend “Caution: federal law prohibits dispensing without a prescription”
|
|
|
|
| primary insurance | the first insurance that the patient will use for claims
|
|
|
|
| prior authorization (preauthorization) | review required to be conducted by a plan before medications are dispensed and, ideally, before they are prescribed
|
|
|
|
| protected health information (PHI) | individually identifiable health information that is transmitted or maintained by electronic media
|
|
|
|
| provider | hospital, physician, and other medical staff members and facilities that offer medical services
|
|
|
|
| Quality Improvement Organization (QIO) | group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to people with Medicare
|
|
|
|
| qui tam | whistle-blower cases
|
|
|
|
| real-time claims management systems | a program that enables providers to submit electronic pharmacy claims in an online real-time environment
|
|
|
|
| relator | person who makes an accusation of suspected fraud
|
|
|
|
| remittance advice (RA) | document that comes to a pharmacy showing the details for a claim (also known as an explanation of benefits)
|
|
|
|
| Remittance Advice Remark Codes (RARC) | non-mandatory codes used to provide further explanation of the basic information provided by the other codes
|
|
|
|
| respondeat superior | law stating that an employer is responsible for employees’ actions
|
|
|
|
| restricted formulary | type of formulary that limits the drugs listed to generics or limited medications within a drug class
|
|
|
|
| safety edits | checks required when a prescription request exceeds a certain quantity limit or dosage, there is potentially dangerous drug interaction, or there are other concerns for the patient’s health
|
|
|
|
| screening service | treatment for a patient who does not have symptoms, abnormal findings, or any past history of a disease
|
|
|
|
| secondary insurance | the insurance used after primary insurance for any remaining expense
|
|
|
|
| special needs plans (SNP) | prescription drug coverage offered by Medicare to some patients with specific needs
|
|
|
|
| specialty drug | category of medication including biotech and other drugs that are designed to treat serious diseases such as cancer, multiple sclerosis, and rheumatoid arthritis and other inflammatory maladies
|
|
|
|
| sponsors | active-duty service members whose spouses and children benefit under TRICARE
|
|
|
|
| State Children’s Health Insurance Program (SCHIP) | program that requires states to develop and implement plans for health insurance coverage for uninsured children
|
|
|
|
| step therapy | edits used to encourage the use of less-expensive, similarly effective generic medications before considering coverage of higher-cost brand-name products
|
|
|
|
| subpoena | order of the court directing a party to appear and testify
|
|
|
|
| subpoena duces tecum | order of the court directing a party to appear, testify, and bring specified documents or items
|
|
|
|
| switch vendor | service used to verify that a claim conforms to NCPDP transaction standards before it is forwarded to the payer’s claim system
|
|
|
|
| Temporary Assistance for Needy Families (TANF) | program that helps with living expenses
|
|
|
|
| therapeutic interchange | substitution of one drug for another in the same therapeutic class
|
|
|
|
| tier | specific list of drugs within a formulary
|
|
|
|
| transactions | electronic data that are regularly sent back and forth between providers, health plans, and employers
|
|
|
|
| treatment, payment, and health care operations (TPO) | term referring to providing and coordinating a patient’s medical care, the exchange of information with health plans, and general business management functions
|
|
|
|
| TRICARE | Department of Defense health insurance plan for military personnel and their families
|
|
|
|
| TRICARE Extra | alternative managed care plan for individuals who want to receive services primarily from civilian facilities and physicians rather than from military facilities
|
|
|
|
| TRICARE for Life | program offered to military personnel to fulfill a promise that they would receive lifelong health care
|
|
|
|
| TRICARE Prime | managed care plan similar to an HMO
|
|
|
|
| TRICARE Reserve Select (TRS) | premium-based health plan available for purchase by certain members of the National Guard and Reserve activated on or after September 11, 2001
|
|
|
|
| TRICARE Standard | fee-for-service program that covers medical services provided by a civilian physician
|
|
|
|
| TrOOP Facilitator | Medicare online eligibility and enrollment system
|
|
|
|
| universal claim form (UCF) | a two-sided document that the pharmacy technician completes and submits for paper claims
|
|
|
|
| usual and customary price (U&C) | the price the provider most frequently charges the general public for a drug
|
|
|
|
| Welfare Reform Act | law that addresses the needs of categorically needy Medicaid recipients
|
|
|
|
| workers’ compensation insurance | plan that provides benefits for someone who is injured accidentally in the course of performing work or a work-related duty or becomes ill as a result of the employment environment
|