Pharmacy Billing and Reimbursement PTCB Practice Test
1. Which government insurance plans offers 4 different parts or areas of different coverage?
A. Medicare
B. Medicaid
C. TRICARE
D. CHAMPVA
2. DAW stand for which of the following?
A. Dispense as written
B. Distribute and work
C. Distribution and working
D. Dispense as well
3. Which of the following third party plans requires the patient to designate a primary care physician (PCP)?
A. Health maintenance organization (HMO)
B. Preferred provider organization (PPO)
C. Medicare Part D D. TRICARE
4. The cost of the coverage of an insurance policy is known as which of the following?
A. Deductible
B. Co-payment
C. Coinsurance
D. Premium
5. Which of the following is another name for the cardholder of the insurance policy?
A. Subscriber
B. Dependent
C. Patient
D. Third party
6. When a patient picks up a prescription in the pharmacy, he or she may be responsible for an out-of-pocket expense known as which of the following?
A. Co-payment
B. Premium
C. Deductible
D. Third party 7. The part of Medicare that covers the costs of prescriptions for Medicare patients is known as which of the following?
A. Part A
B. Part B
C. Part C
D. Part D
8. Which organization oversees Medicaid and Medicare?
A. Food and Drug Administration (FDA)
B. Drug Enforcement Agency (DEA)
C. Centers for Medicare and Medicaid Services (CMS)
D. United States Pharmacopeia (USP)
9. Which of the following is a formulary?
A. A list of insurance companies that offer pharmacy benefits
B. List of providers that are included in an HMO
C. List of approved medications in a member’s plan
D. Recipe for how to make specific medications
10. If a drug is not covered under a patient’s prescription plan, but the prescriber specifically wants the patient to have this medication, the insurance company may require which of the following? A. Formulary
B. Prior authorization
C. Adjudication
D. Coordination of benefits
11. Which code is used for the third party to determine if the proper brand or generic medication was used to fill the prescription?
A. USAN
B. DAW
C. Adjudication
D. Trade
12. Which of the following DAW code is submitted when a generic drug is dispensed or a brand name product that does not have a generic available?
A. DAW 0
B. DAW 1
C. DAW 2
D. DAW 3
13. After a claim has been submitted, what is the process of evaluating a medication for specific drug safety and cost-effectiveness measures known as? A. Coordination of benefits
B. Drug utilization review
C. Prior authorization
D. Coinsurance
14. The deductible is the amount that must be paid when?
A. Each time when prescription is picked up
B. Each year before the policy kicks in
C. Monthly to cover the insurance plan
D. As a percentage of the cost of services
15. If a patient has coinsurance that pays 90% of services, and their prescription cost $50, how much will they owe the pharmacy?
A. $5
B. $10
C. $15
D. $25
16. Which of the following is an example of a third party plan?
A. HOM
B. Prior authorization
C. Adjudication
D. Premium 17. Which of the following is an example of a private insurance company?
A. Medicare
B. Medicaid
C. TRICARE
D. Aetna
18. A patient pays a $500 deductible and a total of $100 in co-pays for the year. The total $600 is called which of the following?
A. Premium
B. Out-of-pocket expenses
C. Coinsurance
D. Point-of-service
19. CMS represents which organizations?
A. TRICARE and Medicare
B. Medicare and Medicaid
C. TRICARE and CHAMPVA
D. CHAMPVA and Medicare
20. To ensure that the maximum benefits are paid, but not duplicated, patients covered under multiple insurance plans will undergo which of the following? A. Adjudication
B. PCN
C. PBM
D. Coordination of benefits
21. Which of the following DAW code is submitted when the patient requests a brand name product, although the prescriber says generic substitution?
A. DAW 1
B. DAW 2
C. DAW 3
D. DAW 5
22. Which of the following information must be gathered from the patient to process an insurance claim?
A. First and last name
B. Birthdate
C. Drug allergy information
D. All of the above
23. Which of the following might have a person number of 3?
A. Member B. Spouse of member
C. Child of member
D. None of the above
24. PCN stands for which of the following?
A. Patient-controlled narcotics
B. Processor control number
C. Pharmacy control number
D. Patient-centered number
25. Which of the following is required to submit an insurance claim?
A. Rx Bin number
B. Rx Group number
C. Patient ID number
D. All of the above
26. What type of pharmacy would pay for a 90-day supply of medication?
A. Retail
B. Mail-order
C. Nuclear
D. Long-term care 27. When is a prior authorization required?
A. A patient is going on vacation
B. A patient has a change in dosage
C. A patient has a prescription for an expensive medication or one not on the formulary
D. A patient only wants a generic drug
28. Which of the following might cause a refill-too-soon rejection?
A. A patient attempts to refill their prescription before the insurance company permits a scheduled fill
B. A patient is going on vacation, and attempts to get a larger quantity than normal
C. A patient had an increased dosage by their physician, and is taking a larger quantity than before so they run out before the scheduled refill date
D. All of the above
29. If a DAW 0 was used, what does this mean?
A. The prescriber wants a name brand dispensed
B. The generic is dispensed or brand name only if there is no generic available
C. The pharmacist wants the patient to have the brand name
D. There is no generic available due to manufacturing or distribution issues 30. A patient is taking an antacid while also on a tetracycline antibiotic. The antacid will cause the antibiotic to cease working. This is an example of which type of DUR rejection?
A. Drug-drug interaction
B. Therapeutic duplication
C. Allergy
D. Contraindication
31. In a PPO, if a patient wants to see a specialist, they must do which of the following?
A. Get a referral from their primary care physician
B. Get approval from the pharmacy
C. See any provider as long as they are in network
D. None of the above
32. Coinsurance is similar to a co-payment, except patients do not pay a flat fee for prescriptions but a ______
A. Premium
B. Cheaper cost
C. Variable rate
D. Percentage of the cost
33. Which of the following would not be covered under Medicare Part A? A. Inpatient hospital stays
B. Prescription drugs
C. Hospice care
D. Home health care services
34. In order to be enrolled in Medicare Part C, a patient must be enrolled in which of the following Medicare parts?
A. Parts A and B
B. Parts A and D
C. Parts B and D
D. None of the above
35. Which of the following would Medicare Part D not cover?
A. DME
B. Lipitor
C. Lisinopril
D. Zetia
36. A patient learns that a medication the doctor has prescribed is not on the approved list of drugs covered by her insurance company. What is this list of drugs called?
A. Adjudication
B. Coordination of benefits C. Pharmacy benefit manager
D. Formulary
37. Most patients enroll in private health care plan through contracts offered by which of the following?
A. The pharmacy
B. The insurance company
C. Their employer
D. None of the above
38. If a patient’s services cost a total of $100, and they are responsible for 20% of the costs, this is known as which of the following?
A. A co-payment
B. A deductible
C. A premium
D. Coinsurance
39. Which part of Medicare covers DME and physician services or outpatient hospital visits?
A. Part A
B. Part B
C. Part C
D. Part D 40. A pharmacy benefit manager processes and pays for drug claims for which of the following?
A. One insurance provider
B. Multiple insurance provider
C. Multiple pharmacies
D. One pharmacy
41. How many numbers is the BIN number on each insurance card?
A. 3
B. 4
C. 5
D. 6
42. If a patient has had his or her coverage terminated, what restricts the pharmacy from accessing information about why the patient no longer has coverage?
A. DEA
B. HIPAA
C. FDA
D. State laws
43. When does a refill-too-soon error occur? A. A patient attempts to get a 90-day supply of a medication
B. A patient attempts to get a name brand of a medication
C. A patient attempts to get their prescription filled before the insurance company permits a scheduled fill
D. A prior authorization is needed
44. You are filling a prescription for a patient who insists on getting the brand name medication. What DAW code would this be?
A. DAW 0
B. DAW 1
C. DAW 2
D. DAW 3
45. DUR stands for which of the following?
A. Drug utilization remission
B. Drug utility recess
C. Drug utilization review
D. Director utilization review
46. A PA is also known as which of the following?
A. Prior authorization B. Part A
C. Premium assistance
D. Pharmacy assistance
47. Which part of Medicare supplies patients with coverage for inpatient hospital stays and nursing facilities?
A. Part A
B. Part B
C. Part C
D. Part D
48. Which of the following is the Part D plan for Medicare?
A. Is a voluntary program for Medicare patients
B. Must be enrolled in during a designated period
C. Is very important for pharmacy technicians to be familiar with
D. All of the above
49. If a patient is pregnant, and given a medication that is a pregnancy class D, this would be considered what type of DUR rejection?
A. Drug-drug interaction
B. Therapeutic duplication
C. Allergy D. Contraindication
50. Which of the DAW code is submitted when the prescriber indicates he or she wants the brand name dispensed?
A. DAW 0
B. DAW 1
C. DAW 2
D. DAW 3