Work Glossary
Terms
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- account
- the term used to describe the second level of the four level process used to determine the benefits of a specific group or member
- active
- a status category used to show that a set of parameters can be used and accessed, such as a line showing eligibility coverage to allow a claim to be paid
- adjudicate
- to process a claim; the billing aspect
- approved amount due
- the total dollar amount approved for the cost of the drug being dispensed; usually including dispensing fee, sales tax, copay, and ingredient cost of the drug
- AWP
- published by MediSpan, this is the wholesale cost of the drug being purchased by the pharmacy from either the manufacturer or wholesaler
- benefit maximum
- the total dollar amount that a group is willing to pay for a calendar year per individual or family
- BET
- an internet-based database of benefit summary information that is grouped by insurance plan
- carrier
- the insurance company; the term used to describe the first level of the four-level process used to determine benefits for a specific group or member
- captured
- the status of a claim that has been entered into RxCLAIMS but has not been paid
- captured program/direct reimbursement
- a program in which a member pays 100% of the approved cost of the prescription when he buys it and then submits a paper claim with the receipt for reimbursement
- CISCO agent desktop telephone system
- a computer-integrated telephone system
- claim
- the transaction in RxC that is submitted by the pharmacy for payment
- AS400/SXC
- RxCLAIMS processing system
- closed formulary
- restricts coverage to the specific drugs listed on the formulary
- compounded prescription
- a custom-made drug created with specified ingredients into special doses and dosage forms
- compounded prescription billing
- the billing a pharmacy must submit using the most expensive ingredient in the drug with an NDC number
- CCD
- A Lotus Notes database containing alerts, grids, and other important client/product/process info
- CCD alert
- a temporary piece of info that helps agents; an important addition to the CCD containing client, product, or process info, and with requires immediate agent attention
- co-payment
- a fixed dollar amount payable per prescription
- co-insurance
- a fixed percentage of the cost of the prescription
- DAW (dispense as written)
- this must be followed exactly by the pharmacy when filling the prescription
- NDPS (no drug product selection)
- when the doctor specifies a drug to dispense it is indicated with this; state law requires this on all prescriptions the doctor writes out
- PSC (prescribers selection code)
- code indicating prescriber's instructions concerning generic substitutions
- deductible
- an amount which the insured person must pay before the plan pays
- differential
- the price difference between the generic and the brand drug
- dispensing fee
- the amount that a par pharmacy wants for giving out the prescription
- DOB
- date of birth
- DOS
- date of service
- DUR (drug utilization review)
- this RxC process happens during the Rx verification/adjudication phase as a safety check
- edit/DUR
- the function executed by RxC to check over 700 variables of a claim to ensure the claim is correct; it must successfully pass all 700 edits
- effective date
- the date the coverage or start date of the specified info is considered effective
- embedded program
- a prog in which a mem pays 100% of the approved cost of the prescript when he/she has it filled
- exception
- an error or unusual circumstance related to a claim that requires special review before the order can go any futher
- FileNet
- a virtual file cabinet that allows an individual to look at an electronic version of the actual prescription that has been scanned into the system
- fill date
- the date the prescription was dispensed by the pharmacy
- formulary
- a carrier-defined list of preferred or recommended drugs
- generic drug
- an exact duplicate of a brand drug
- generic indicator
- the field in RxC that identifies the brand or generic status of a drug (O, Y N, M)
- GPI (generic product indicator)
- the 14 digit code used to lump therapeutically equivalent drugs; also can be used to set different restrictions to the entire class of drugs
- group
- the third level of the four level process to determine the benefits for a specific group or member; the member's employer
- hold out of stock
- a temporary shortage of a certain medication which delays the mail order by one business day
- hotkey/hotspot
- a field in RxC which is usually pink/purple in color; the user may place the cursor on this and use the F4 to take a shortcut to the needed screen
- inactive
- this is the status where a set of parameters cannot be used
- ingredient cost
- the amount submitted by the pharmacy stating what the actual cost of the drug was to them
- infinity date
- a future date entered to indicate eligibility: 12/31/39
- MAC (maximum allowable cost)
- this is set by us on most products in our database (also used by RxC pricing progs to determine the Mandatory Generic or Generic Pref Program)
- maintenance drug
- a long term prescribed drug
- maintenance drug list
- a list of drugs to be used long-term
- mandatory generic claim/generic driver
- a claim against a plan which prefers its member to use generic products
- member
- the fourth level in the four-level process for determining benefits; an individual covered by a client's insurance plan
- msa
- a contact center agent who services members
- psa
- a contact center agent who provdes services to pharmacists
- MyRxHealth.com
- an internet site which contains a variety of prescription-related info; functions include pharmacy locating and refilling prescriptions
- NABP# (National Association of Board of Pharmacy)
- a unique seven-digit number assigned by the NCPDP to each licensed pharmacy
- NDC (National Drug Code)
- the FDA-given 11-digit number assigned to each federally approved drug in the country
- NCPDP (National Council Prescription Drug Program)
- the org that sets the national standard for electronic prescription claim systems and pharmacies
- open coverage
- this is coverage that has a termination date of some variable time in the future, so it will allow a claim to pay online as long as the line is still active
- open formulary
- drug list that includes all drugs
- otc
- the status of a drug that can be purchased without a prescription
- par
- a pharmacy in our network
- u&c (usual and customary)
- an amount the pharmacy submits for every claim that details the best price for that particular day/insurance/drug
- senior service agent/lead
- an individual in the contact center who is assigned to assist agents with complicated processes
- step therapy
- this is a process where a member must try other lower dosage drugs before being given the prior authorization to use the more potent drugs (these potent drugs have been IDed as frequent or potential misued/overuse/inappropriate use that could be of economical/clinical concern)
- submit date
- the date the pharmacy submits the claim on line (not to be confused with paid date)
- third party exception code
- a code defined and maintained by MediSpan that lumps similar drugs together for possible rejection of claims; ie., if a group has designed their benefit structure to reject coverage for smoking deterrents, then a third party exception code edit can be entered on the plan code for that purpose
- quantity
- the field will show the number of units that were dispensed for a specific prescription
- reject
- if the order does not meet the defined benefits and thus not be payable, this is what happens to it
- reject code
- a two-digit number that states the specific reason for rejection
- reversal
- this is when a pharmacy submits a claim but determines it was an error or not meant to be paid by us and will negate the claim
- route of administration
- the field that indicates how the patient will take a specific drug
- RxC number
- a 14-digit number assigned to every claim that comes into the system; this time stamp can be used to search for a specific claim
- Rx number
- the seven-digit number assigned to a specific claim that is submitted by the pharmacy
- pv1
- a quality control check conducted by a pharmacist to verify that a prescription was entered properly in the RxExp during data entry
- pv2
- a quality control check conducted by a pharmacist to verify that the proper medication at the proper dosage was dispensed to fill a mail order prescription
- pharmacy network
- pharmacies contracted with an insurer, PBM, or managed care organizations
- PBM (pharmacy benefit manager)
- a third-party vendor who manages pharmacy benefits for healthcare plans
- pharmacy
- the place where prescriptions are dispensed
- partially-closed formulary
- a drug list that specifies the drugs covered, but allows exceptions, usually with additional cost sharing (such as higher co-pay) or administrative effort (such as prior authorization)
- plan
- this is a code of guidelines on using insurance to obtain prescriptions
- prescriber ID
- the number that details which doctor prescribed the drugs
- PA (prior authorization)
- a special approval needed to have a certain drug otherwise not not allowed to be allowed
- product
- medication
- production
- when electronic claims are being processed and users can maintain/add info in the RxC
- PrimeMail
- mail order pharmacy, located in Irving, TX