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Center for Curriculum and Transfer Articulation
Pharmacy Benefits Account Management
Course: CSR161

First Term: 2009 Summer I
 Lec + Lab   3 Credit(s)   5 Period(s)   4.4 Load  
Subject Type: Occupational
Load Formula: S


Description: Member account services for pharmacy benefits management. Covers state and federal regulations regarding controlled substances as well as order placement and problem solving procedures. Also includes eligibility issues, participant account management, and procedures for completing test claims.



MCCCD Official Course Competencies
1. Differentiate between various eligibility types. (I)
2. Demonstrate procedures for resolving participant eligibility issues. (I)
3. Explain features of an interactive voice response system. (II)
4. Provide non-technical web support to callers. (II)
5. Demonstrate procedures for updating participant account information. (III)
6. Explain procedures for completing fulfillment calls. (IV)
7. Locate network retail pharmacies. (V)
8. Complete refill orders. (V)
9. Identify potential refill problems and appropriate solutions. (V)
10. Explain State and Federal regulations governing controlled medication. (VI)
11. Locate a National Drug Code number (NDC#). (VI)
12. Complete a test claim. (VI)
13. Identify controlled substances. (VI)
14. Demonstrate order status problem solving techniques. (VII)
15. Determine co-payments. (VIII)
16. Determine retail pharmacy refill limitations. (VIII)
17. Explain account financial restrictions. (VIII)
18. Use the account balance screen. (VIII)
19. Interpret account balance statements. (VIII, IX)
MCCCD Official Course Competencies must be coordinated with the content outline so that each major point in the outline serves one or more competencies. MCCCD faculty retains authority in determining the pedagogical approach, methodology, content sequencing, and assessment metrics for student work. Please see individual course syllabi for additional information, including specific course requirements.
 
MCCCD Official Course Outline
I. Eligibility
   A. Demographic Details
   B. Access
   C. Types
   D. Issue Resolution
      1. Status Verification
      2. Resolution Manager
      3. Mail Order
      4. Retail
   E. Verification
   F. Documentation
II. Self Services
   A. Interactive Voice Response System
      1. Description
      2. Use
      3. Benefits
      4. Features
   B. Web
      1. Use
      2. Features
      3. Support
III. Account Maintenance
   A. Address/Phone Change
      1. Call Flow
      2. Screens
   B. E-Mail
      1. Add
      2. Change
   C. Credit Card Function
      1. Add
      2. Change/Delete
      3. Features
IV. Fulfillment Calls
   A. Process Flow
      1. Literature Request
      2. Statement of Cost
   B. Prescription Cards
   C. Website Requests
      1. Procedures
      2. Restrictions
   D. Resolution Manager
V. Order Placement
   A. Mail
      1. Services
      2. Benefits
      3. Initial Fill
      4. Refill
      5. Cost Evaluation
      6. Problem Resolution
   B. Retail
      1. Network Pharmacy
      2. Cost Evaluation
      3. Benefits
      4. Problem Resolution
VI. Drugs
   A. Regulations
      1. Federal
      2. State
   B. Classifications
   C. National Drug Code Number (NDC#)
   D. Detail
      1. Screens
      2. Procedures
   E. Test Claims
      1. Use
      2. Procedures
   F. Face Value
      1. Calculations
      2. Restrictions
   G. Controlled Substances
      1. Identification
      2. Schedules
      3. Rules
      4. State Laws
VII. Order Status
   A. Process Flow
   B. Problem Solving
      1. Problem Identification
      2. Solution Choice
      3. Action
      4. Follow Up/Evaluation
   C. Screens
      1. Prescription Detail
      2. Verify Order
   D. Codes
VIII. Plan Design
   A. Definition
   B. Use
   C. Rules
   D. Information
      1. Dispensing Pharmacy
      2. Need To Know
      3. Delivery Systems
      4. Clinical Programs
   E. Procedures
      1. Quantity Limitations
      2. Co-Payments
      3. Account Balance
      4. Refills
      5. Pre-Authorization
      6. Paper Claims
   F. Codes
      1. Billing/Reporting
      2. Client
      3. Retail Input
   G. Kits
   H. Financial Restrictions
      1. Deductible
      2. Maximum Out-of-Pocket (MOOP)
      3. Maximum Allowable Benefit (MAB)
IX. Account Balance
   A. Statement
      1. Information
      2. Interpretation
   B. Payments
      1. Options
      2. Procedures
   C. Client Financials
   D. Refunds
 
MCCCD Governing Board Approval Date:  5/26/2009

All information published is subject to change without notice. Every effort has been made to ensure the accuracy of information presented, but based on the dynamic nature of the curricular process, course and program information is subject to change in order to reflect the most current information available.