Billing and Reimbursement
PTCB
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Credentials
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Certificate
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Feature your advanced understanding of third-party payers and reimbursement systems utilized within the pharmacy.
INTRO
Expertise in managing billing and reimbursement is crucial in the pharmacy setting. However, this competency is often lacking or learned through experience that allows a tech to solve only a few specific issues without developing a broad foundation. Earning the PTCB Billing and Reimbursement Assessment-Based Certificate will demonstrate that you not only have the necessary foundational knowledge but you are capable of playing a leadership role in this crucial administrative function for a pharmacy, which helps patients access medication.
Complete the Billing and Reimbursement Certificate to demonstrate your competency in:
- Insurance programs and eligibility requirements
- Claim processing and adjudication
- Prior authorizations
- CMS audits and contract compliance
PREPARE & APPLY
Back to TopA Step Toward Your Advanced CPhT (CPhT-Adv)
Earning this certificate takes you one step closer to becoming a PTCB Advanced Certified Pharmacy Technician® (CPhT-Adv®). Active PTCB CPhTs who have completed at least four of the certificate programs, or three certificate programs and the Compounded Sterile Preparation Technician® (CSPT®) Certification, and 3 years of work experience will be eligible to earn a CPhT-Adv credential.
Eligibility Requirements
A candidate must hold an active PTCB CPhT Certification and fulfill one of the following eligibility pathways:
Pathway 1: Completion of a PTCB-Recognized Billing and Reimbursement Education/Training Program and at least 6 months of experience as a pharmacy technician, at least 50% of which must be devoted to pharmacy billing and reimbursement activities.
Pathway 2: At least 12 months of full-time employment with pharmacy technician experience; at least 50% of which must be devoted to pharmacy billing and reimbursement activities.
Candidates are required to complete and upload the Supervisor Attestation Form for the PTCB Billing and Reimbursement Certificate Program at the time of application submission.
Educational Requirement
One of the eligibility pathways for this certificate program includes completing a PTCB-Recognized Education/Training Program for the Billing and Reimbursement Certificate. PTCB-Recognized Programs have been reviewed and found to provide learners with foundational knowledge that will help them be successful on PTCB exams. Please note that PTCB-Recognized Programs may not cover all information that appears on your exam. It is important that you review the exam content outline as part of your preparation and seek supplemental resources as needed.
Exam Fee
The cost to apply for this certificate exam is $89.
How to Apply and Schedule
- Apply by logging into your PTCB Account.
- Once your application is approved, you will receive an email with your authorization to schedule your exam.
The Billing and Reimbursement Certificate Exam is administered through online proctored testing and in-person at more than 1,400 Pearson Test Centers nationwide, including more than 100 military on-base sites.
Prepare for Your Exam
Online Testing Requirements Overview
This quick video explains the requirements and policies for online proctored testing.
Pearson Tutorial
The Pearson tutorial provides a preview of the testing experience and functionality for PTCB exams.
Exam Content Outline
The Billing and Reimbursement Exam covers several knowledge areas organized into four domains. Be sure to review the exam content outline as part of your exam preparation.
| Programs and Eligibility (26.67%) |
| Insurance programs and terminology (e.g., Medicare [Parts A, B, and D], Medicare Advantage, Medicaid [MCO, FFS], private insurance [HMO, PPO], copay, coinsurance) |
| Third-party reimbursement types (e.g., Pharmacy Benefit Managers [PBMs], patient assistance programs [PAPs], Medication Prescription Payment Plans [MPPPs]) |
| Healthcare reimbursement systems in different settings (e.g., home health, long-term care, home infusion, hospitals, community pharmacy, ambulatory clinics) |
| Eligibility requirements for federally-funded insurance programs (e.g., Medicare, Medicaid, TRICARE) |
| Eligibility requirements for financial assistance programs and 340B programs |
| Pharmacy Claims Processing and Adjudication (36.67%) |
| Pharmacy claim processing terminology (e.g., adjudication, formulary, non-formulary, third-party billing, payer, Collaborative Practice Agreements) |
| Information required to submit pharmacy billing claims |
| General pharmacy claim submission process (e.g., data entry, verification, adjudication) |
| Third-party claim rejection troubleshooting and resolution |
| Methods for determining drug cost and sale prices (e.g., AWP, dispensing fees, gross and net profit, acquisition cost, 340B cost) |
| Coordination of benefits (i.e., process to determine payer(s) and patient responsibilities) |
| Reimbursement policies for all plans being billed, regardless of contracted payers, HMOs, PPO, CMS, or private plans |
| Process to determine formulary coverage and formulary alternatives |
| Medical Claims Processing and Adjudication (8.33%) |
| Clinical services performed by pharmacists that can be billed as medical claims (e.g., annual wellness visits, chronic care management, continuous glucose monitoring) |
| Medical claim processing terminology (e.g., Medicare Administrative Contractors [MACs], HCPCS codes, modifiers, ICD codes, Collaborative Practice Agreements, CMS categorization of providers and personnel, medically unlikely to edit [MUE], bulk charges) |
| Information required to submit medical billing claims, including “incident to” billing (e.g., Level I and II HCPCS codes, level of supervision, service location) |
| Prior Authorization (18.33%) |
| Prior authorization terminology (e.g., ePA, formulary exception, quantity limitation, Collaborative Practice Agreements, appeals, external review) |
| Information required to submit medical/pharmacy prior authorization (e.g., patient and prescriber information, drug, dose) |
| General process of prior authorization |
| Third-party prior authorization rejection troubleshooting and resolution |
| Audits and Compliance (10.00%) |
| Audit and compliance terminology, including accrediting bodies and surveys (e.g., URAC, The Joint Commission, CMS, DNV) |
| Documentation requirements for claims billed to federally-funded insurance programs (e.g., Medicare, Medicaid, TRICARE) |
| Federal laws, regulations, and requirements pertaining to CMS and HRSA audits |
| Purpose and process for different types of audits (e.g., desktop, additional documentation request [ADR], Targeted Probe and Educate [TPE], Comprehensive Error Rate Testing [CERT], Recovery Audit Contractors [RAC], manufacturer audit, payer audit) |
| Quality assurance documentation required for compliance with government agencies, prescription drug plans, and PBMs |
EARN YOUR CERTIFICATE
Back to TopAbout the Exam
The Billing and Reimbursement Certificate Exam is a computer-based exam with 75 multiple-choice questions. Be prepared to commit 1 hour and 30 minutes for the exam (5-minute tutorial, 1 hour and 20-minute exam, and 5-minute post-exam survey).
Exam Day Requirements
When you schedule your exam, you may choose to take your PTCB exam at a Pearson test center or online from your own computer under the virtual supervision of a live proctor.
- Arrive at the designated Pearson test center 30 minutes prior to your appointment. If you are testing online, check-in 30 minutes prior to your appointment.
- Bring an approved form of identification that matches your name as it appears on your PTCB Account. You will not be allowed to take the exam without proper identification.
- Prior to your exam day, be sure to review more details about what to expect and important information about online testing requirements in our Help Center.
Testing Accommodations
Candidates who require testing accommodations must request these accommodations during the application process. Accommodations that are reasonable and consistent with the Americans with Disabilities Act (ADA) will be provided by PTCB at no additional cost to candidates. Learn more.
NEXT STEPS
Back to TopScoring
The passing scaled score is 300. The range of possible scores based on the exam content outline is 0 to 400. Your official score report will be presented on screen following your exam. If you pass the exam, your credential status can be verified through PTCB Certification Verification.
Certificates
Once your official score is available, you can download your certificate through the Credly Platform. Learn more.
Digital Badges
Upon earning your credential, you will receive an email invitation from the Credly Platform via badge@ptcb.org with instructions for claiming your badge and setting up your account.
This digital badge will contain information describing your credential, including how you earned it. You can display the badge in your email signature, electronic files of a resume, and on social media sites like LinkedIn, Facebook, and Twitter.
Renew
This certificate program does not require renewal.
DOCUMENTS
Back to TopQuick access to additional documents you may need during this process. Download the necessary documents and submit the completed forms as required.