Credentialing Guidelines and Requirements

Scope

PTCB Billing and Reimbursement certificate holders have demonstrated their advanced understanding of third-party payers and reimbursement systems utilized within the pharmacy. Individuals who earn the certificate will demonstrate that they not only have the necessary foundational knowledge but are capable of playing a leadership role in this crucial administrative function for a pharmacy, which helps patients access medication. 

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 experience as a pharmacy technician, 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.

Exam

Candidates are required to pass the Billing and Reimbursement Exam to earn the PTCB Billing and Reimbursement Certificate. The Billing and Reimbursement Exam is a computer-based exam with 70 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 Content Outline

The Billing and Reimbursement Exam covers several knowledge areas organized into four domains, as shown in the following table.

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 (e.g., 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)

 

Exam Passing Score

A panel of subject-matter experts established a passing score for the Billing and Reimbursement Exam using industry best practices. The method used by the panel, as directed by a psychometrician, is the modified-Angoff method. This method requires experts (panel members) to evaluate individual test questions and estimate the percentage of qualified pharmacy technicians that would be able to answer each question correctly. These estimates were analyzed for consistency and averaged to produce the passing score. The passing score and candidate results are reported as scaled scores. The passing scaled score for the Billing and Reimbursement Exam is 300. The range of possible scores based on the exam content outline is 0 to 400.

Advanced Certified Pharmacy Technician Credential

Earning your Billing and Reimbursement 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.