Insurance and Billing
Navigate third-party payers with confidence.
Module overview
Insurance is the #1 source of friction at the pharmacy counter. Understanding the players, the codes, and the common rejections is what separates a slow technician from a fast one.
What you'll learn
- 01Third-party billing
- 02Prior authorizations
- 03Medicare and Medicaid basics
- 04Claim rejection troubleshooting
Lessons
Who's who in pharmacy benefits
Patient → Plan → PBM → Pharmacy. Each layer has a job and a place where things go wrong.
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Card fields you'll enter
BIN, PCN, Group, Member ID, Person Code — get these right and the claim routes correctly.
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Medicare and Medicaid
Government programs cover ~40% of U.S. prescriptions and have unique billing rules.
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Common rejections and what to do
Knowing the top NCPDP rejection codes saves hours per week.
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Prior authorizations
PAs require the prescriber to justify the medication to the payer before coverage applies.
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Key terms
- PBM
- Pharmacy Benefit Manager — processes prescription claims and manages drug coverage for plans.
- BIN
- Bank Identification Number — 6-digit routing number on an insurance card.
- Adjudication
- Real-time processing of a pharmacy claim returning copay and coverage.
- Formulary
- List of drugs covered by a specific insurance plan, often tiered by copay.
Study tool
Flashcards
01 / 19
Click the card to reveal the answer.
Practice questions
- Q1What does NCPDP rejection 75 mean?
- Q2Which Medicare part covers most outpatient prescriptions?
- Q3Where do you find the BIN on an insurance card?
Weekly study rhythm
- • Watch the module lecture video
- • Complete guided notes and flashcards
- • Take the end-of-lesson quiz
- • Practice pharmacy calculations daily
- • Take a mock exam every two modules