Which entity administers prescription drug benefits on behalf of health plans and negotiates with pharmacies, manufacturers, and plan sponsors?
Ptcb Billing Reimbursement Programs And Eligibility
Question · Easy
HMO vs PPO
Short
A Medicare beneficiary needs a nebulizer solution (albuterol unit-dose) to use at home with a nebulizer machine. Under which Medicare part is this typically billed?
Question · Medium
Company that administers prescription drug coverage for employers, insurers, and other plan sponsors.
Coverage and eligibility
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Introduction & Exam Overview
0.1 PTCB Billing & Reimbursement Exam Facts
Study guide
What does the BIN field on a pharmacy insurance card identify in an NCPDP claim?
Ptcb Billing Reimbursement Claims Processing
Read the clue and guess the term in 6 tries.
Game
NCPDP reject code 79 indicates what issue?
Medicare Advantage plan that generally limits care to its network and, in most cases, requires a referral before a specialist visit.
NCPDP reject code 70 indicates what issue?
The Birthday Rule Breakdown
NCPDP reject code 75 indicates what issue?
Ptcb Billing Reimbursement Prior Authorization
Medicare Advantage plan whose in-network doctors cost less but which generally still lets you use outside doctors for covered care at a higher price.
0.2 Blueprint Breakdown & Study Strategy
NCPDP reject code 76 indicates what issue?
Swap tiles to line up three of the same term.
Term Match
A claim rejects with code 88 (DUR Reject Error) and an additional reason code of TD (Therapeutic Duplication). What is the most appropriate first step?
Order in which two insurers pay one claim: the first pays up to its coverage limits, then sends the remaining balance to the second.
Claims and billing
A patient brings a prescription for brand-name Synthroid, but the prescriber has not authorized a generic substitution. Which DAW code is submitted on the claim?
Life and health terms people mix up
In 2026, what is the annual out-of-pocket maximum a Medicare Part D enrollee will pay before entering catastrophic coverage?
Medicaid-contracted plan that receives a set monthly payment per member to deliver covered services.
Chapter 1: Third-Party Programs & Eligibility
1.1 Commercial Insurance & Managed Care Models
What is the maximum Medicare Part D annual deductible allowed for 2026?
Flip two cards at a time to find matching terms.
Term Pairs
Which Medicare Part D coverage phase was eliminated starting in 2025 under the Inflation Reduction Act?
ANSI-accredited pharmacy standards developer that publishes the Telecommunication, SCRIPT and Post Adjudication standards.
Which plan type typically requires patients to select a primary care physician and obtain referrals for specialist visits?
Which federal program provides healthcare coverage to active-duty military, retirees, and their eligible family members?
Six-digit code a health plan obtains from the pharmacy standards group to route electronic claims when its card lacks a magnetic stripe.
1.2 Medicare Pharmacy Coverage: Parts A, B, C, and D
Medicaid is a healthcare program administered by:
Find five hidden terms in a grid of letters.
Term Search
A patient has both primary commercial insurance and secondary Medicaid coverage. How must the pharmacy bill the prescription?
Secondary identifier a plan may define to separate benefit packages during claim routing.
When submitting a secondary claim to a PBM after the primary has paid, which field must include the amount already paid by the primary plan?
Question · Hard
Which field on a pharmacy benefit card uniquely identifies the specific enrolled patient?
Industry benchmark figure for drugs; Medicare Part B's payment limit for certain vaccines is 95 percent of it.
1.3 Medicaid, Dual Eligibles, & Government Safety-Net Programs
Which organization publishes the standards used for real-time electronic pharmacy claim adjudication in the United States?
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The Usual and Customary (U&C) price submitted on an NCPDP claim represents what?
State Medicaid program that caps reimbursement for certain multi-source drugs, alongside the federal upper limit.
MAC (Maximum Allowable Cost) pricing is most commonly used for which drug class?
What does AWP stand for in pharmacy pricing?
Product-selection field whose code 1 means the prescriber did not permit a generic substitution, while code 0 means none was indicated.
1.4 Military, Veterans, & Worker's Compensation Programs
A commercial plan requires step therapy for a brand proton pump inhibitor. What does 'step therapy' mean?
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