Network Terminology

2. A unique Tx Number for every claim/transaction processed through our switch.
6. The highest amount a coupon or program will pay toward a prescription.
9. On Demand Automated copay buy-down solution in Rx Assist when commercial coverage applies.
10. Numeric system to identify drug products in the United States
12. Card provided by manufacturers to reduce patient copay
13. Tool used to confirm/update pharmacy demographics, services, and script-routing information.
16. Messaging providing education and awareness solution in Rx Assist.
19. Tool used to search for plan information.
22. The process of offsetting out-of-pocket expenses for a prescription.
24. Eligibility Transaction
25. A unique 10-digit identifier issued to healthcare providers for billing
26. Tool used to view claim details and history.
28. Entity that manages prescription drug benefits for insurers.
30. The process of verifying if a patient qualifies for a program or benefit
31. Tech company that provides applications to a pharmacy allowing them to process and track prescriptions.

1. Approval required from insurance before dispensing certain medications.
3. The current state of a pharmacy claim (e.g., paid, denied, pending)
4. An Optum Network service that allows a pharmacy customer to search for patient eligibility/processing information.
5. Messaging or changes applied to a claim after the Payor adjudicates and prior to returning to the Pharmacy.
7. The average purchase cost of a drug product from a wholesaler.
8. A six-digit number used to route pharmacy claims
11. Claim A claim that is not approved for payment.
14. A field that indicates whether a patient has alternative insurance coverage and if the insurance is denying or paying towards the claim.
15. Claim status when a pharmacy submits a claim for payment or reversal where there is a matching request already on file.
17. Provides copay assistance when commercial coverage is blocked or denied.
18. Code used by the processor to identify the specific plan associated with the BIN
19. Pharmacy Network Admin Center
20. Different steps in a claim process that can help identify any PPE edits that may have applied.
21. Tool that allows you to view claim details for a specific rx submitted multiple times within a 90 day period.
23. Billing Transaction
27. A message or change applied to a claim prior to being sent to the Payor.
29. Reversal Transaction