Which item is NOT part of the adjudication process?

Which item is NOT part of the adjudication process?

• A. Prior authorization requirements processing
• B. Determination of patient drug coverage eligibility
• C. Determination of patient co payment
• D. Determination of reimbursement amount to the pharmacy

Answer: (D)

Adjudication is the claim-processing step where the payer determines how a prescription fits the patient’s benefits: whether the drug is covered, what the patient’s share will be (copay or coinsurance), and whether any prior authorization is required. Processing prior authorization, checking patient eligibility for the plan, and calculating the patient’s copayment are all part of that step because they directly affect whether the claim will be approved and what the patient owes at the point of sale. The reimbursement amount to the pharmacy, however, is governed by negotiated contract rates and allowed amounts and is handled in the payment/settlement phase rather than during adjudication. So the item about the reimbursement amount to the pharmacy is not part of adjudication.

Adjudication is the claim-processing step where the payer determines how a prescription fits the patient’s benefits: whether the drug is covered, what the patient’s share will be (copay or coinsurance), and whether any prior authorization is required. Processing prior authorization, checking patient eligibility for the plan, and calculating the patient’s copayment are all part of that step because they directly affect whether the claim will be approved and what the patient owes at the point of sale. The reimbursement amount to the pharmacy, however, is governed by negotiated contract rates and allowed amounts and is handled in the payment/settlement phase rather than during adjudication. So the item about the reimbursement amount to the pharmacy is not part of adjudication.