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Insurance companies: what to look for when processing claims

Insurance can be a major distraction along with mfg coupons. Pharmacy insurance cards, coupon and discount cards all have information that needs to be entered into the computer for the patient to get the best price. The PBM or pharmacy Benefits Manager is the processor of claims for the insurance company and requires this information. There is always a BIN number which stands for bank identification number and is used to identify which provider is to receive the claim. There is also a PCN or processor control number which routes the claim even further. The group number further routes the claim to the group that the patient belongs to and the ID number is the exact locater for that patient. There are also member numbers for each member of the family that is insured. There are as many different ways of getting a reject as there are insurance cards. When claims are transmitted to the insurance carrier, or adjudicated, they can be accepted or rejected. When processing, the wrong info can be entered whether it’s the wrong insurance company, group, id number or updated changes that the patient just doesn’t have. Some plans require the Dr’s DEA number others need the NPI. At times there may be meds that require prior authorizations due to price, quantity or days’ supply especially with opioids. Sometimes it can be rejected for the drug not being on the formulary or being too soon to refill. There are also some claims that require an ICD code, which stands for International Classification of Disease. These are diagnosis codes that the MD will assign to the patient’s disease state for reimbursement and pharmacies may need to use these to correspond to the therapy. Some rejections are due to mandatory mail order usage which is getting more prominent. As insurance companies are getting into the mail order business, they can require their clients to use mail order for chronic meds. There is also a COB claim which requires the primary plan to be billed first and then a MFG coupon to be used in coordination to further reduce the copay to the patient. Each rejection takes time to resolve based on the operating system that you are using. It is best to talk with your pharmacist about the best way solve these problems in your setting.

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