Insurance Coverage of OTC Oral Contraceptives: Lessons from the Field

Appendix Table 2: Steps to Submitting a Pharmacy Claim
1. Pharmacy enters information required to bill insurance into its computer system, including the patient’s insurance, the drug or product, the prescriber’s national provider identification number (NPI), and other relevant information. This can be performed by a pharmacist, pharmacy technician, or clerk.

2. Pharmacy submits the claim using the National Council for Prescription Drug Programs (NCPDP)’s standard. NCPDP sets the HIPAA standard for pharmacy claims.

3. The claim reaches what is referred to as a “switch,” which acts as a gate keeper to ensure the claim reaches the correct pharmacy benefit manager (PBM) or other payer.

4. The claim contains values associated with the patient that identifies the PBM/payer the claim should be sent to.

    • BIN – Bank Identification Number
    • PCN – Processor Control Number
    • Group# – Group Number is not always required; some plans only use BIN & PCN
    • Member ID

5. The PBM/payer receives the claim for processing.

6. After processing, the PBM/payer returns the claim back to the originating pharmacy through the “switch” with either an approval or a denial. There are other processes that might require the PBM/payer to return a claim containing more information before final processing.

7. An approved claim will provide the pharmacy with the amount being paid and the amount of copayment to collect from the patient (if any).

8. Actual payment to the pharmacy (money transfer) occurs at a later date based on the parties’ contractual agreement.

SOURCE: Kevin Gorospe, PharmD, Principal, Gorospe Solutions LLC

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