Learning Objectives: At the completion of this program, participants will be able to:

• Define program and eligibility terminology
• Outline third-party reimbursement types (e.g., PBM, medication assistance programs, self-pay)
• Describe healthcare reimbursement systems in different settings (e.g. home health, long-term care, home infusion, health systems, community pharmacy, and ambulatory clinics)
• Outline the eligibility requirements for federally-funded insurance programs (e.g., Medicare, TRICARE, Medicaid)
• Outline the eligibility for patient assistance through available programs (e.g. a 340B eligible program)
• Define commonly used terms used in processing and adjudicating prescription claims
• Analyze information needed to successfully submit and process claims for prescriptions and medical devices
• Describe the life cycle of a prescription claim-form order entry to completed claim
• Identify listed formulary alternatives or plan limitation restrictions to guide prescribers
• Outline reimbursement variations across different payor sources
• Explain the Federal 340B program and related terminology
• Define commonly used terminology in prior authorizations
• List the information needed to submit medical/pharmacy prior authorization
• Outline the process of prior authorizations 
• Resolve and trouble-shoot third-party prior authorization rejections
• Define common billing audit and compliance terminology
• List documentation needed for claims to be billed and processed with insurance
• Outline federal laws and/or regulations for billing and reimbursement
• Identify billing and reimbursement accrediting bodies and surveys
• Define common billing audit and compliance terminology
• List documentation needed for claims to be billed and processed with insurance
• Outline contract documentation needed for claims billed to specific insurance plans
• Outline the standard audit process
• Outline federal laws and/or regulations regarding audits
• Identify billing and reimbursement accrediting bodies and surveys

Accreditation Information: The National Pharmacy Technician Association (NPTA) is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing education. This CPE activity has been designated as a knowledge-based program. No faculty members had any conflicts of interest to disclose.

ACPE UAN: 0384-9999-20-303-H04-T 

4 contact hours/ 0.4 CEU

Release Date: 10-01-2020 Expiration Date: 10-01-2023

Please note: Participants who complete this program must review and consult with their individual State Board of Pharmacy and employer to verify eligibility to complete billing and insurance and ensure compliance with all applicable laws and regulations.

All purchases are non-refundable and non-transferrable.