Insurance Billing and Rejections: A Pharmacy Tech Guide

How Pharmacy Insurance Billing Works

When a patient presents a prescription, the pharmacy submits an electronic claim to the insurance plan through a pharmacy benefits manager (PBM). The claim includes the drug NDC number, quantity, days supply, prescriber NPI, and patient information. The PBM adjudicates the claim in real time, returning either an approval with copay information or a rejection with a code explaining why.

Common Rejection Codes

• 75 - Prior Authorization Required - The drug needs PA approval before the plan will cover it
• 76 - Plan Limitations Exceeded - Quantity or days supply exceeds plan limits
• 79 - Refill Too Soon - The patient is requesting a refill before the expected run-out date
• 70 - Product/Service Not Covered - The drug is not on the plan's formulary
• 88 - DUR Reject - Drug utilization review identified a potential problem (interaction, duplication, etc.)
• MR - Prescriber Not Covered - The prescriber is not in the plan's network

Resolving Rejections

For each rejection type, technicians can take specific actions:

• Prior authorization - Contact the prescriber's office to initiate the PA process
• Quantity limits - Adjust the quantity or days supply to match plan limits, with pharmacist approval
• Refill too soon - Calculate the expected run-out date and schedule the fill accordingly, or contact the plan for an override if the patient has a valid reason (vacation, lost medication)
• Not covered - Check for a covered alternative within the same drug class and contact the prescriber
• DUR reject - Alert the pharmacist to review and override if clinically appropriate

Coordination of Benefits

Patients with multiple insurance plans require coordination of benefits (COB). The primary plan is billed first, and the secondary plan is billed for any remaining balance. Common situations include patients with employer insurance plus Medicare, or patients covered by both parents' plans.

Insurance processing skills are tested on the PTCE and used daily in practice. Sharpen these skills with PTCB practice questions.