| Programs and Eligibility (20%) |
| Programs and eligibility terminology |
| Third-party reimbursement types (e.g., PBM, medication assistance programs, self-pay) |
| Healthcare reimbursement systems in different settings (e.g. home health, long-term care, home infusion, health systems, community pharmacy, and ambulatory clinics) |
| Eligibility requirements for private and/or federally-funded insurance programs (e.g., Medicare, TRICARE, Medicaid) |
| Eligibility for patient assistance through available programs (eg. a 340B eligible program) |
| Claims Processing and Adjudication​ (48%) |
| Pharmacy/medical claim processing terminology |
| Information needed to submit pharmacy/medical claims |
| General pharmacy claim submission process (e.g., data entry, verification, adjudication) |
| Third-party claim rejection trouble-shooting and resolution |
| Methods for determining drug cost and sale prices (e.g., AWP, dispensing fees, gross and net profit, acquisition cost |
| Coordination of benefits or plan limitations to determine each party’s responsibility |
| Reimbursement policies for all plans being billed, regardless of contracted payers, HMOs, PPO, CMS, or commercial plans |
| Identification of formulary coverage or alternatives |
| 340B terminology |
| Prior Authorization (20%) |
| Prior authorization terminology |
| Information needed to submit medical/pharmacy prior authorization (e.g., patient and prescriber information, drug, dose) |
| General process of prior authorization (e.g., from formulary alternatives to contacting the provider, then through payer to patient) |
| Third-party prior authorization rejection trouble-shooting and resolution |
| Audits and Compliance (12%) |
| Audit and compliance terminology |
| Contract documentation for claims billed to specific insurance plans (e.g., ICD-10 codes, provider feedback and authorizations to change medications) |
| Federal laws/regulations regarding audits (e.g., mandated audits by CMS for all government funded programs) |
| Accrediting bodies and surveys (e.g., URAC, TJC, CMS, DNV) |
