PTCB Question Walkthrough: Insurance and Billing

Insurance and Billing Questions on the PTCB Exam

Insurance processing and billing is a major component of pharmacy technician work and the PTCB certification exam. These questions test your knowledge of claim adjudication, rejection codes, coordination of benefits, and formulary management. This walkthrough breaks down common question types.

Question 1: DAW Codes

A patient requests the brand-name medication even though a generic is available. Which DAW code should be used?

• A. DAW 0
• B. DAW 1
• C. DAW 2
• D. DAW 5

Correct Answer: C

Explanation: DAW 2 indicates "patient requested brand." DAW 0 means no preference (substitution allowed), DAW 1 means the prescriber requested brand (dispense as written), and DAW 5 means generic is not available. Knowing DAW codes is essential for proper insurance billing and is frequently tested on the PTCB exam.

Question 2: Coordination of Benefits

A patient has two insurance plans. After the primary plan pays, what happens next?

• A. The patient pays the remaining balance
• B. The secondary plan is billed for the remaining amount
• C. The pharmacy absorbs the remaining cost
• D. The prescriber is contacted for a formulary alternative

Correct Answer: B

Explanation: In coordination of benefits (COB), the primary insurance is billed first. After the primary plan pays its portion, the remaining balance is submitted to the secondary insurance plan. The secondary plan then pays according to its own coverage rules. The patient is responsible for any remaining copay after both plans have processed.

Question 3: Common Rejection Codes

A claim is rejected with the message "Refill Too Soon." What is the most appropriate next step?

• A. Override the rejection and dispense the medication
• B. Check the patient's last fill date and determine if an early fill is warranted
• C. Tell the patient their insurance has been canceled
• D. Call the insurance company to demand an override

Correct Answer: B

Explanation: A "Refill Too Soon" rejection means the insurance calculates that the patient should still have medication remaining from their last fill. The technician should check the patient's fill history to determine the appropriate next fill date. If there is a legitimate reason for early refill (vacation, lost medication, dose change), the pharmacy may contact the insurance for an override. Never override without proper authorization.

Question 4: Prior Authorization

What does a prior authorization (PA) require?

• A. The pharmacy must approve the medication
• B. The prescriber must provide clinical justification to the insurance plan
• C. The patient must prepay for the medication
• D. The manufacturer must discount the medication

Correct Answer: B

Explanation: A prior authorization requires the prescriber to submit clinical documentation to the insurance plan justifying why a specific medication is needed. This is commonly required for non-formulary drugs, high-cost medications, or drugs with utilization management criteria. The pharmacy technician's role is to initiate the PA process by notifying the prescriber's office and tracking the request status.

Insurance Billing Tips for the PTCB Exam

• Memorize common DAW codes (0, 1, 2)
• Understand the difference between primary and secondary insurance
• Know common rejection reasons and appropriate responses
• Understand step therapy, quantity limits, and prior authorization processes
• Know the difference between formulary tiers and their cost implications

Practice insurance billing questions at PTCBprep mini exams and study at PTCBprep.