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 be eligible for this exam, you must have an active PTCB CPhT Certification and complete one of the following eligibility pathways:

  1. Completion of PTCB-Recognized Education/Training Program for the Billing and Reimbursement Certificate and at least 6 months of experience as a pharmacy technician
  2. At least 12 months of pharmacy technician experience; at least 50% of which must be committed to pharmacy billing and reimbursement functions

The Billing and Reimbursement Exam cost is $89.

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

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