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.
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.
Pathway 2: At least 12 months of pharmacy technician experience; at least 50% of which must be devoted to pharmacy billing and reimbursement activities.
Passing the Billing and Reimbursement Exam is required to earn the PTCB Billing and Reimbursement Certificate. The Billing and Reimbursement Exam is a computer-based exam administered at Pearson VUE test centers nationwide. The Billing and Reimbursement Exam is a 1.5-hour, multiple-choice exam that contains 70 questions. One hour and 20 minutes are allotted for answering the exam questions and 10 minutes are allotted for a tutorial and 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|
|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)|
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.
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 (must include TPV or Medication History), 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.