The Billing and Reimbursement Certification gives you the proficiency in managing billing and reimbursement in a pharmacy setting. After earning this certification, you will show your proficiency in:

• Insurance programs and eligibility requirements
• Claim processing and adjudication
• Prior authorizations
• CMS audits and contract compliance

Earn your certificate by passing the 70 multiple-choice questions while given the 1.5 hours for the exam broken up in this way:

• Programs and Eligibility 20%
• Claims Processing and Adjudication 48%
• Prior Authorization 20%
• Audits and Compliance 12%
  
  

To learn more about NPTA’s related training programs, such as the Immunization Administration, click here.

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Learning Objectives:

 At the completion of this program, participants will be able to:

• define prior authorization terminology

• list information needed to submit medical/pharmacy prior authorization

• describe the general process of prior authorization 

• perform third-party prior authorization and rejection trouble-shooting and resolution

• define commonly used terms used in processing and adjudicating prescription claims

• analyze information needed to successfully submit and process claims for prescriptions and medical devices

• describe the life cycle of a prescription claim- from order entry to completed claim

• identify the listed formulary alternatives or plan limitation restrictions to guide prescribers

• outline reimbursement variations across different payer sources

• explain the Federal 340B program and related terminology

• outline third-party reimbursement types (e.g., PBM, medication assistance programs, self-pay)

• list healthcare reimbursement systems in different settings (e.g. home health, long-term care, home infusion, health systems, community pharmacy, and ambulatory clinics)

• outline eligibility requirements for federally-funded insurance programs (e.g., Medicare, TRICARE, Medicaid)

• outline eligibility for patient assistance through available programs (e.g. a 340B eligible program)

• define common billing audit and compliance terminology

• recognize documentation needed for claims to be billed and processed with insurance.

• outline federal laws and/or regulations for billing and reimbursement

• list billing and reimbursement accrediting bodies and surveys

 

Accreditation Information:

The National Pharmacy Technician Association (NPTA) is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing education. This CPE activity has been designated as a knowledge-based program. No faculty members had any conflicts of interest to disclose.

ACPE UAN: 0384-9999-20-002-H04-T 

4 contact hours/ 0.4 CEU

Release Date: 10-01-2020 Expiration Date: 10-01-2023