Billing and Reimbursement for Pharmacy Technicians

   
The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education with Commendation.

These activities are intended for pharmacy technicians who are seeking to update their knowledge and skills regarding billing and reimbursement. This program is a PTCB-Recognized Education/Training Program for their Billing and Reimbursement Assessment-Based Certificate Program.

After participating in this CPE activity, learners should be able to:

Programs and Eligibility
ACPE Number: 0204-0000-23-073-H04-T

• Discuss terminology for programs and eligibility.
• List eligibility requirements for insurance programs.
• List third-party reimbursement types.
• Explain healthcare reimbursement systems in different settings.
• Describe eligibility for various patient assistance programs, including income-based, through available programs.

Claims Processing and Adjudication
ACPE Number: 0204-0000-23-074-H04-T

• Discuss terminology for pharmacy/medical claim processing.
• List information needed to submit pharmacy/medical claims.
• Explain the general pharmacy claims submission process.
• Discuss strategies for third party claim rejection trouble-shooting and resolution.
• List methods for determining drug cost and sale prices.
• Discuss reimbursement policies for all plans including formulary coverage or alternative substitutions.

Prior Authorization
ACPE Number: 0204-0000-23-075-H04-T

• Discuss prior authorization terminology.
• Review insurance guidelines and information needed for submission of prior authorizations.
• Explain the general process of prior authorization.
• Discuss strategies for third party prior authorization rejection trouble-shooting and resolution.
• Discuss the process for prior authorization appeals, denials, or requests and formulary evaluations 

Audits and Compliance
ACPE Number: 0204-0000-23-076-H04-T

• Discuss audit and compliance terminology.
• Review required contract documentation for claims billed to specific insurance plans.
• Discuss federal laws and/or regulations regarding audits.
• Explain required documentation in response to various audits.
• Explain roles of survey / accrediting organizations.
• Identify quality assurance documentation required for compliance with government agencies, prescription drug plans, and pharmacy benefit managers.

Mary Ann Kliethermes, PharmD, B.S.
Director of Medication Safety and Quality
American Society of Health-system Pharmacists
Bethesda, Maryland

Michael Green, PharmD
Lead Clinical Pharmacist
Barnes Jewish Hospital
St. Louis, Missouri

Nichole Foster, MBA, Med, CPhT
Program Director, Pharmacy Technician Training Program
Vanderbilt Medical Center
Nashville, Tennessee

In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support and the Accreditation Council for Pharmacy Education’s Standards for Commercial Support, ASHP requires that all individuals involved in the development of activity content disclose their relevant financial relationships. A person has a relevant financial relationship if the individual of his or her spouse/partner has a financial relationship (e.g. employee, consultant, research grant recipient, speakers bureau, or stockholder) in any amount occurring the in the last 12 months with a commercial interest whose products or series may be discussed in the educational activity content over which the individual has control. The existence of these relationships is provided for the information of participants and should not be assumed to have an adverse impact on the content.

All faculty and planners for ASHP education activities are qualified and selected by ASHP and required to disclose any relevant financial relationships with commercial interests. ASHP identifies and resolves conflicts of interest prior to an individual’s participation in development of content for an educational activity. Anyone who refuses to disclose relevant financial relationships must be disqualified from any involvement with a continuing pharmacy education activity.

All planners, presenters, and reviewers of this session report no financial relationships relevant to this activity.

Activities can be completed in any order. Each activity consists of audio, video, and/or PDFs and evaluations. Learners must review all content and complete the evaluations to receive continuing pharmacy education credit for each activity.

Follow the prompts to claim, view, or print the statement of credit within 60 days after completing the activity.