Third Party Processing

847 Words2 Pages

Shaymous Juhnke
Third Party Processing
Third party processing is a process that all community pharmacies need to do in order to get paid through insurance. The exact process of how the claims get processes may be different from pharmacy to pharmacy, but as a whole the process is similar. For my IPPE my location was at CVS in a Target store. The first thing that happens is that the prescription comes into the pharmacy. This can either be through fax, e-script, phone, transfer, or physical copy. After the information about the prescription is entered in to the computer it is sent to the triage que. In this que, we double check that the information is entered correctly, enter in or change a SIG code, enter days’ supply, and address other …show more content…

The first case where it is processed differently is if something is billed though Medicare part B. some example of things which are billed though part D include DME durable medical equipment, such as cane and nebulizer equipment, test strips, vaccines. When these are processed, we need to get a signature from the patient stating what we are filing to be valid. He stated with Medicare there are multiple different forms to be sent to Medicare. Another Issue with billing is when a patient has more than one insurance, but this can be handed in CVSs main filling program allowing for the billing of multiple insurances. Additionally, if a patient has a government insurance and a private insurance provider the private insurance is run first and then the government insurance is processed …show more content…

They ensure that this is done correctly is making sure that the information on the prescription matches what is dispensed and entered into the computer, and if issues arise at the cash register they also assist there also. Additionally, making sure that the correct diagnosis codes are entered into the computer as well. The most common error is days supplied being enter improperly. Having an error such as incorrect days supply can increase the amount of time it takes for a claim to get processed and therefore increasing the amount of time it can take to get that claim paid. When a claim is submitted incorrectly a pharmacist needs to call and corrected it. My preceptor said that technically anything entered incorrectly about the prescription can result in missed reimbursements through insurance. Although most issues that occur are handled through CVSs main processing hub such as claims, reimbursements, and charge backs. The CVS is the entity responsible for making sure claims are getting paid, and what the store gets back are totals of payments received but not a detailed breakdown of individual records of each

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