Carrier: Also known as the insurer or provider, refers to the patient’s insurance company.
Processor: Company hired by the insurer to process claims on their behalf.
Adjudication: Process of electronically transmitting a prescription to the patient’s insurance company or third-party biller for approval and billing.
Claim: A request for reimbursement from a healthcare provider to the insurance provider for services rendered.
Co-pay: Portion of costs paid out-of-pocket by the patient; insurance covers the rest.
Deductible: Set amount the client pays upfront before insurance coverage starts.
Example
Medication costs $150.
Co-pay: $50
Insurance covers: $100
If deductible is $150, the patient pays the full amount at first until the deductible is met.
Insurance Card Information
Processor Bank Identification Number (BIN): Six-digit number used to process electronic pharmacy claims, identifying the third-party payer.
Processor Control Number (PCN): Further refines BIN, specifying exact processing requirements.
Member Identification Number: Unique identifier for each member to ensure correct billing and coverage.
Person Code: Differentiates individuals within a family on a health plan, vital for precise family plan billing.
RX Group Number: Specifies the pharmacy benefits an individual or group is entitled to.
Steps in Insurance Billing Process
Collect Essential Patient Information
Name, address, marital status, and date of birth.
Ensure data matches insurance provider records.
Transmit Prescriptions Accurately
Include medication name, strength, dose.
Indicate if a generic option is available.
Include dispense as written code if required for branded drugs.
Submit Claims Electronically
Submit claim to the insurance provider or third-party claims processor.
Importance
Understanding and navigating these processes ensure efficient and accurate claims processing, contributing to effective healthcare delivery.