PTCB Billing & Reimbursement study plan

Define the core billing vocabulary (claim, adjudication, formulary, copay, coinsurance, deductible, allowed amount, remittance) in your own words without notes

Compare the major payer categories - commercial, Medicare Part D, Medicaid, Tricare, workers' compensation, cash - on eligibility rules, formulary control, and copay structure

Diagram the end-to-end claim lifecycle from prescription intake to payer adjudication to remittance posting

Identify the member and cardholder data elements required on every claim (BIN, PCN, group number, person code, relationship code) and state why each exists

Convert between 10-digit labeler NDC formats and the 11-digit billing format by applying the correct padding rule for each segment

Calculate days supply from directions, quantity dispensed, and dosage form for at least 15 varied prescriptions, including PRN and tapered directions

Interpret dispensing-accuracy and substitution codes and explain how each changes reimbursement

Distinguish allowed amount, ingredient cost, dispensing fee, and patient pay amount within a single adjudicated claim

Sequence the steps of electronic claim transmission from data entry through switch routing to payer response

Map the major claim data fields to their purpose and required format so no field is entered from guesswork

Differentiate a rejected claim from a denied claim and predict which one can be corrected and resubmitted same-day

Assemble a pre-submission verification checklist covering eligibility, formulary status, quantity limits, and prior-authorization flags

Resolve five coordination-of-benefits scenarios by determining primary versus secondary payer and calculating the secondary payment

Compute patient out-of-pocket cost across deductible, copay, and coinsurance stages for the same drug in three benefit designs

Explain how prior authorization, step therapy, and quantity limits alter the claim outcome and what documentation each requires

Trace how a manufacturer copay card or discount program interacts with a patient's deductible and accumulator

Calculate reimbursement from acquisition cost, dispensing fee, and contractual adjustments for 10 representative claims

Compare AWP, WAC, and maximum allowable cost as pricing benchmarks and state the practical limitation of each

Distinguish gross profit from net profit after direct and indirect remuneration fees and identify where fee recovery is possible

Audit a sample remittance advice to reconcile expected payment against actual payment and flag variances

Categorize the most common rejection and denial codes by root cause: eligibility, coverage, coding, refill-too-soon, and authorization

Select the correct corrective action for each root-cause category and state the expected turnaround

Draft a complete prior-authorization request and a complete appeal letter using payer-acceptable clinical justification

Document interventions in a manner that would survive a payer audit

Distinguish fraud, waste, and abuse using concrete pharmacy billing examples for each

Outline the pharmacy's obligations under audit, record retention, and privacy rules, including what to produce and what never to disclose

Identify red-flag billing patterns that trigger recoupment and describe the self-correction step for each

Assemble a monthly compliance self-audit routine with named checkpoints and a responsible role for each

Synthesize all four domains by working 60 mixed practice items under timed conditions

Diagnose your two weakest sub-areas from the practice results and re-study each with targeted notes

Re-derive the calculation types from memory: days supply, NDC padding, patient pay, COB secondary payment, and net reimbursement

Rehearse explaining a denial and its resolution aloud as you would to a prescriber's office