PTCB Billing & Reimbursement study guide
PTCB Billing & Reimbursement · Work through your exam, one topic at a time.
The PTCB Billing and Reimbursement certificate is a credential for pharmacy technicians who want to show competence in the business side of pharmacy - the part of the workflow between a prescriber's order and a paid claim. It fits technicians already working in community, specialty, or mail-order settings, and those moving from dispensing duties into billing, prior authorization, or revenue-cycle work. It also helps where employers are consolidating reimbursement tasks into the technician role. The exam is organized into four areas of equal emphasis: pharmacy billing fundamentals and payer types; prescription claims processing and submission; reimbursement, copays, and coordination of benefits; and denials, rejections, appeals, and compliance. The PTCB Billing & Reimbursement study guide has 4 sections and about 1,354 words.
01Pharmacy Billing Fundamentals and Payer Types
Start with payer categories. Commercial (private) plans are administered by a PBM and reimburse under a contracted network rate.
352 words, about 2 min02Prescription Claims Processing and Submission
A pharmacy claim is submitted in real time under the NCPDP Telecommunication Standard. The pharmacy management system assembles the required fields: BIN, PCN, group, cardholder ID and person code, date of service, the 11-digit NDC in 5-4-2 format (pad with leading zeros, never truncate), metric quantity, days supply, DAW code, prescriber NPI, submission clarification code, other coverage code, and patient pay amount.
334 words, about 2 min03Reimbursement, Copays, and Coordination of Benefits
The reimbursement formula is ingredient cost plus dispensing fee. Ingredient cost is generally the lesser of the contracted rate (AWP minus a percentage, or MAC) and the pharmacy's U&C.
344 words, about 2 min04Denials, Rejections, Appeals, and Compliance
Read rejection codes literally. Codes a candidate should recognize: 41, submit bill to another payer; 70, NDC not covered; 75, prior authorization required; 76, plan limitations exceeded such as quantity or age limits; 79, refill too soon; 88, DUR conflict.
324 words, about 2 min