PTCB Billing & Reimbursement key terms

An organization other than the patient that pays or manages payment for prescription drugs, such as an insurer, PBM, Medicare, or Medicaid.

A company that administers pharmacy benefits for health plans, including formulary management, claims adjudication, network contracting, and payment to pharmacies.

A joint federal-state health program that covers eligible low-income people and often pays for prescriptions under state-specific rules, formularies, and reimbursement methods.

The optional Medicare prescription drug benefit delivered through private stand-alone or Medicare Advantage plans, with formularies, premiums, copays, and coverage phases.

A health plan offered by a private insurer, often through an employer or individual policy, that covers prescriptions according to its benefit design and pharmacy network.

A payer's list of covered drugs, often organized into cost-sharing tiers, with prior authorization or quantity limits applied to selected medications.

A fixed dollar amount a patient pays for a covered prescription at the pharmacy, separate from deductible or coinsurance amounts.

A percentage of the allowed prescription cost that a patient pays after any deductible, while the plan pays the remaining percentage.

The amount a patient must pay out of pocket for covered drugs before the plan begins paying its share, unless the plan exempts certain products.

A unique 11-digit code identifying a drug's labeler, product, and package size; pharmacies submit it on claims to identify exactly what was dispensed.

The numeric amount of medication supplied, expressed in the billing unit required by the payer, such as tablets, capsules, milliliters, or grams.

The estimated number of days the dispensed quantity will last a patient when used according to the prescriber's directions; payers use it for utilization checks.

A claim field indicating whether a pharmacist substituted a different product than prescribed and the reason, which can affect reimbursement or patient cost.

The Bank Identification Number on a pharmacy card identifies the payer's claims processor and routes an electronic prescription claim to the correct adjudication system.

A Processor Control Number used with the BIN to identify the specific benefit plan or processing arrangement for an electronic pharmacy claim.

An identifier on a member's insurance card that links the patient to a particular employer group or benefit package within a payer's system.

The unique identifier assigned by a payer to an enrolled person; pharmacies use it to verify eligibility and submit claims for the correct individual.

An electronic or paper request from a pharmacy to a payer for payment of a dispensed prescription, containing patient, drug, and billing information.

A transaction that cancels a previously submitted or paid pharmacy claim so it can be corrected, resubmitted, or removed from the payer's records.

An electronic claim submitted at the pharmacy counter that is adjudicated in real time, allowing the pharmacy to collect the patient's cost share immediately.

The payer's automated review of a pharmacy claim against eligibility, formulary, coverage, and pricing rules to determine payment or rejection.

A claim the payer has adjudicated and approved for payment, producing a patient responsibility amount and an expected pharmacy reimbursement.

A claim that fails initial edits or lacks required data and is not adjudicated, often requiring correction and resubmission before payment can be considered.

A claim processed by the payer but not paid because coverage criteria were not met, such as missing prior authorization or a non-covered drug.

A standardized or payer-specific message explaining why a claim was rejected, such as invalid member ID, missing prior authorization, or quantity exceeding a limit.

A payer approval required before certain drugs are covered, demonstrating that clinical criteria are met; without it, a claim may be denied.

A coverage rule requiring a patient to try one or more preferred, usually lower-cost drugs before the payer will approve a different medication.

A payer's maximum reimbursement limit for a drug, often based on generic pricing; pharmacies may lose money if acquisition cost exceeds that limit.

A published average wholesale price used as a benchmark in some drug reimbursement formulas, though actual pharmacy acquisition costs are often lower.

The portion of a prescription reimbursement attributed to the drug product itself, calculated from a pricing benchmark or contracted rate before adding dispensing fees.

A fixed amount added to ingredient cost to reimburse the pharmacy for professional services, packaging, overhead, and other dispensing-related costs.

The process of determining which health plan pays first when a patient has multiple coverages, then coordinating remaining benefits to avoid duplicate payment.

The health plan that pays first on a claim when a patient has more than one coverage, according to coordination-of-benefits rules.

A health plan that pays after the primary payer, often covering some or all of the remaining patient responsibility or unpaid balance.

A statement from a payer explaining how a claim was processed, including allowed amounts, payments, denials, and the patient's financial responsibility.

An electronic or paper payment notice sent to a pharmacy that lists claims paid, adjusted, or denied and the amounts paid or recouped.

A payer's review of pharmacy claims and records to verify that billing, dispensing, and documentation complied with contract and coverage requirements.

A process in which a payer or PBM recovers money from a pharmacy for claims later found invalid, ineligible, or incorrectly priced.

The withholding or recovery of previously paid claim money by a payer, often through future remittances, after an audit or overpayment finding.

A formal request by a prescriber, pharmacy, or patient to reconsider a denied claim or coverage decision, usually with supporting clinical documentation.