PTCB Quiz Prep

Pharmacy Billing and Insurance Practice Questions

Updated · aligned to the 2026 PTCE outline

Third-party claims, DAW codes, rejection handling and the fields that make an adjudication go through.

13 questionsAnswers includedUntimedEvery answer cited100% free

Key takeaways

  • DAW 0 is no product selection indicated, the default for most generic fills.
  • DAW 1 is prescriber requests brand. DAW 2 is patient requests brand.
  • BIN and PCN route the claim to the correct processor. A wrong BIN rejects the claim outright.
  • Prior authorization is a payer decision, not a pharmacy one. The prescriber initiates it.

Billing is the part of the job most new technicians learn on the floor rather than in a book, which is exactly why the exam tests it. A claim that rejects is a patient standing at the counter, and knowing which rejection means what turns a ten-minute problem into a one-minute one.

DAW codes are the reliably testable piece here. There are ten of them, 0 through 9, and the exam cares most about 0, 1 and 2.

Want the same material as a timed, randomized run instead? Try the timed Order Entry quiz and the Order Entry & Processing domain guide.

All 13 billing & insurance questions and answers

Each answer is followed by an explanation and a link to the primary source it was checked against.

  1. 1. What is the primary function of the BIN on a patient's prescription insurance card?

    • A.It identifies the patient's copay tier within the plan
    • B.It is a six-digit number that routes the electronic claim to the correct claims processor
    • C.It verifies that the prescriber is enrolled with the plan
    • D.It records which pharmacy dispensed the prescription

    Answer: B. It is a six-digit number that routes the electronic claim to the correct claims processor

    The BIN (Bank Identification Number, field 101-A1) is a six-digit number required on every electronic pharmacy claim; the industry uses it to route the transaction to the correct payer or processor. It works together with the PCN, group number, and cardholder ID, which are collectively known as the 4Rx data.

    Source: ncpdp.org

  2. 2. A patient's insurance card lists RxBIN, RxPCN, RxGRP, and a member ID. What role does the PCN play when the claim is transmitted?

    • A.It sets the maximum days supply the plan will pay for
    • B.It identifies the patient's relationship to the cardholder
    • C.It replaces the BIN when the plan is government funded
    • D.It acts as a secondary routing identifier that directs the claim to the correct benefit within the processor

    Answer: D. It acts as a secondary routing identifier that directs the claim to the correct benefit within the processor

    The Processor Control Number (PCN) is used together with the BIN as part of the 4Rx data to fine-tune claim routing, pointing the transaction to the specific plan or benefit configuration inside a processor. Relationship to the cardholder is conveyed by the person code and relationship fields, not the PCN.

    Source: cms.gov

  3. 3. A claim transmitted for a maintenance medication returns NCPDP reject code 79. What is the plan communicating?

    • A.The prescriber is not covered by the plan
    • B.The drug requires step therapy before coverage
    • C.The refill is being requested too soon after the previous fill
    • D.The cardholder ID was entered incorrectly

    Answer: C. The refill is being requested too soon after the previous fill

    Reject code 79 is Refill-Too-Soon, meaning the plan's records show the patient should still have medication remaining from the last fill. Most plans allow the refill to process once roughly 75-80% of the previous days supply has elapsed.

    Source: primewest.org

  4. 4. A new prescription claim rejects with NCPDP code 75, "Prior Authorization Required." What is the most appropriate next step for the pharmacy team?

    • A.Notify the prescriber's office so a prior authorization request can be initiated with the plan
    • B.Resubmit the same claim until it pays
    • C.Change the days supply to a smaller value and resubmit
    • D.Dispense the medication and bill the plan later

    Answer: A. Notify the prescriber's office so a prior authorization request can be initiated with the plan

    Reject 75 means the plan will not pay until the prescriber obtains prior authorization, so the prescriber's office must submit clinical justification to the insurer. Resubmitting unchanged claims or altering the days supply does not resolve a PA requirement, and dispensing without an approved claim risks nonpayment unless the patient chooses to pay cash.

    Source: primewest.org

  5. 5. A claim rejects with NCPDP code 70, "Product/Service Not Covered." How does this rejection differ from a prior authorization rejection?

    • A.Code 70 means the pharmacy is out of network for this patient
    • B.Code 70 means the quantity exceeds the plan's limit for one fill
    • C.Code 70 means the claim must first be billed to a different payer
    • D.Code 70 means the drug is excluded from the plan's benefit rather than pending approval

    Answer: D. Code 70 means the drug is excluded from the plan's benefit rather than pending approval

    Reject 70 indicates the billed product is not a covered benefit of the plan, often because of a formulary or plan exclusion. Unlike reject 75, where coverage is possible once a prior authorization is approved, an excluded product generally requires a formulary alternative, a formulary exception request, or cash payment.

    Source: primewest.org

  6. 6. While billing a new patient's first prescription, the claim rejects as "M/I Cardholder ID Number." What should the technician do first?

    • A.Ask the pharmacist to override the rejection
    • B.Bill the prescription to the pharmacy's house account
    • C.Compare the ID number entered in the system with the number printed on the insurance card and resubmit
    • D.Tell the patient the plan has terminated coverage

    Answer: C. Compare the ID number entered in the system with the number printed on the insurance card and resubmit

    M/I stands for missing/invalid, so reject 07 usually signals a typo or omission in the cardholder ID field. The technician should verify every character against the physical or electronic card, correct the entry, and retransmit before assuming there is a true eligibility problem.

    Source: primewest.org

  7. 7. A Medicaid claim returns NCPDP reject code 41, "Submit bill to other processor or primary payer." What does this rejection indicate about the patient's coverage?

    • A.The patient has no active prescription coverage of any kind
    • B.The patient has another insurance plan that must be billed first, with Medicaid as a later payer
    • C.The pharmacy's NCPDP number is not on file with the state
    • D.The prescription is too old to be billed to any plan

    Answer: B. The patient has another insurance plan that must be billed first, with Medicaid as a later payer

    Reject 41 signals a coordination of benefits issue: the plan's records show other primary coverage, so the claim must be billed to that primary payer first. Medicaid is the payer of last resort, and the technician should collect the primary plan's billing information and rebill in the correct order.

    Source: primewest.org

  8. 8. A claim for a covered dependent child rejects with "M/I Person Code." What does the person code identify on a pharmacy claim?

    • A.The specific individual, such as cardholder, spouse, or dependent, covered under the cardholder's plan
    • B.The prescriber's license classification
    • C.The pharmacy employee who entered the claim
    • D.The therapeutic category of the billed drug

    Answer: A. The specific individual, such as cardholder, spouse, or dependent, covered under the cardholder's plan

    The person code distinguishes each covered family member under the same cardholder ID, commonly 01 for the cardholder, 02 for a spouse, and higher numbers for dependents. Submitting the wrong person code makes the plan unable to match the claim to the correct member, which triggers reject 08.

    Source: primewest.org

  9. 9. A prescriber writes "brand medically necessary" on a prescription for Synthroid and does not authorize substitution. Which DAW code belongs on the claim?

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

    Answer: A. DAW 1

    DAW 1 indicates that substitution is not allowed by the prescriber, which is the correct code when the prescriber demands the brand product. DAW 0 means no product selection was indicated, and DAW 2 applies when the patient, not the prescriber, requests the brand.

    Source: resdac.org

  10. 10. A prescriber allows generic substitution for atorvastatin, but the patient insists on receiving brand-name Lipitor. Which DAW code should the technician submit?

    • A.DAW 1
    • B.DAW 7
    • C.DAW 0
    • D.DAW 2

    Answer: D. DAW 2

    DAW 2 means substitution was allowed but the patient requested that the brand product be dispensed. Plans often apply a higher copay or charge the patient the cost difference in this situation, so coding it accurately matters for correct billing.

    Source: resdac.org

  11. 11. A pharmacy has temporarily run out of the generic version of a drug, so the pharmacist dispenses the brand product even though substitution was permitted. Which DAW code reflects this situation?

    • A.DAW 8
    • B.DAW 4
    • C.DAW 3
    • D.DAW 2

    Answer: B. DAW 4

    DAW 4 indicates substitution was allowed but the generic drug was not in stock at the pharmacy. DAW 8 is different: it applies when the generic is not available in the marketplace at all, not just out of stock locally.

    Source: ilyouthcare.com

  12. 12. Which situation is correctly billed with DAW 0?

    • A.The prescriber requires the brand product to be dispensed
    • B.State law mandates that the brand product be dispensed
    • C.No product selection instruction was given and the generic is dispensed
    • D.The patient asks the pharmacy to order the brand product

    Answer: C. No product selection instruction was given and the generic is dispensed

    DAW 0 means no product selection was indicated, which is the default code used when substitution is permitted and the pharmacy dispenses the generic (or the only available product). Prescriber-required brand is DAW 1, a legal mandate is DAW 7, and a patient request for brand is DAW 2.

    Source: resdac.org

  13. 13. A state's generic substitution law requires the brand product of a narrow therapeutic index drug to be dispensed for a specific patient population, even though the prescriber did not mark the prescription. Which DAW code applies?

    • A.DAW 7
    • B.DAW 1
    • C.DAW 9
    • D.DAW 6

    Answer: A. DAW 7

    DAW 7 means substitution is not allowed because the brand drug is mandated by law or regulation, making it the correct code when a legal requirement, rather than the prescriber or patient, forces brand dispensing. DAW 1 requires an explicit prescriber instruction, which is absent here.

    Source: resdac.org

Billing & Insurance: FAQ

What are DAW codes?

Dispense As Written codes, numbered 0 through 9, that tell the payer why a brand or generic was dispensed. DAW 0 means no selection was indicated, DAW 1 means the prescriber required the brand, and DAW 2 means the patient requested it. The code affects reimbursement and patient copay.

What do BIN and PCN mean on an insurance card?

BIN is the Bank Identification Number, a six-digit code that routes the claim to the correct processor. PCN is the Processor Control Number, which the processor uses to direct the claim to the right plan within its system. Both must be entered correctly or the claim rejects.

Can a pharmacy technician start a prior authorization?

A technician can identify that a prior authorization is required and initiate the paperwork or electronic request, but the prescriber has to supply the clinical justification and the payer makes the decision. The pharmacy cannot approve one.

Official sources checked

Every answer above was written against a primary source and verified independently. These are the 5 sources behind this set.

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