CPBRS (BRS-001) Exam Objectives

This exam certifies that the candidate has the technical knowledge and skills to manage the pharmacy revenue cycle, from benefit verification and prior authorization to claim submission and denial management.

Domain 1: Benefit Verification and Prior Authorization (30%)

• Benefit Investigation: Perform a comprehensive benefit investigation to determine a patient's coverage under both medical and pharmacy benefits.
• Prior Authorization (PA): Manage the end-to-end PA process, including submission of clinical documentation, follow-up, and peer-to-peer appeals.
• Financial Assistance: Identify and enroll eligible patients in manufacturer and foundational patient assistance programs.

Domain 2: Billing, Coding, and Claim Submission (40%)

• Pharmacy Benefit Billing: Submit claims using appropriate NDC numbers, quantities, and days' supply, and manage common claim rejections.
• Medical Benefit Billing: Submit claims for "buy-and-bill" medications using appropriate HCPCS (e.g., J-codes) and CPT codes for administration.
• Coding Principles: Apply knowledge of ICD-10 codes to support medical necessity for a claim.
• Coordination of Benefits (COB): Manage billing processes when a patient is covered by multiple insurance plans.

Domain 3: Denial Management and Appeals (20%)

• Denial Analysis: Identify the root cause of claim denials by interpreting payer remittance advice and explanation of benefits (EOB) documents.
• Appeal Process: Develop and submit effective written and verbal appeals to overturn denied claims.
• Trend Analysis: Analyze denial trends to identify and correct systemic issues in the billing process.

Domain 4: Compliance and Financial Analysis (10%)

• Payer Contracts and Audits: Understand the key terms of a payer contract and how to prepare for and respond to a PBM audit.
• DIR Fees: Describe the impact of Direct and Indirect Remuneration (DIR) fees on pharmacy reimbursement.
• Fraud, Waste, and Abuse: Identify and report potential instances of healthcare fraud, waste, and abuse.

Eligibility Requirements

To be eligible to sit for a CPS certification exam, candidates must meet the criteria outlined in one of the two pathways below.

Pathway 1: For U.S. Licensed Pharmacists

This pathway is for pharmacists licensed to practice within the United States, regardless of country of graduation.

• Hold an active and unrestricted pharmacist license in any state or territory of the United States.
• Meet educational requirements by being a graduate of an ACPE-accredited school of pharmacy or holding a Foreign Pharmacy Graduate Examination Committee® (FPGEC) Certificate.
• Fulfill the specialty experience requirement as outlined below.

Pathway 2: For International Pharmacists (Non-U.S. Licensed)

This pathway is for pharmacists who practice outside of the United States.

• Hold an active and unrestricted license to practice pharmacy in their country of practice. A certified English translation of the license must be provided if the original is not in English.
• Hold a professional degree in pharmacy equivalent to a U.S. pharmacy degree, such as a Bachelor’s degree (BPharm), Master’s degree in Pharmacy Practice (MPharm), or Doctor of Pharmacy degree (PharmD).
• Fulfill the specialty experience requirement as outlined below.

Specialty Experience Requirement (for all pathways)

To ensure candidates have foundational knowledge in the specialty, one of the following criteria must be met:

• Standard Pathway:
  Completion of at least one year of professional experience in a practice setting directly related to the certification area.
• Certificate Pathway:
  The one-year specialty experience requirement is waived for candidates who hold an active certificate of completion from a nationally recognized provider in a related subject matter. This includes, but is not limited to, the completion of a relevant PGY residency, fellowship, certificate/training program, or a relevant graduate degree (e.g., a Master's degree in the specialty field). Recognized providers of certificate programs include, but are not limited to:
  • American Society of Health-System Pharmacists (ASHP)
  • American Pharmacists Association (APhA)
  • American College of Clinical Pharmacy (ACCP)
  • American Society of Consultant Pharmacists (ASCP)

Career Path for CPBRS Professionals

The CPBRS certification is essential for pharmacists and experienced technicians in roles focused on the pharmacy revenue cycle. It is valuable in specialty pharmacy, health-system, home infusion, and community pharmacy settings.

Target Candidates

• Pharmacists and technicians working in prior authorization, billing, or patient access roles.
• Specialty or health-system pharmacy staff involved in the revenue cycle.
• Pharmacy leaders responsible for the financial performance of their department.

Primary Job Roles:

• Reimbursement Specialist
• Prior Authorization Specialist
• Pharmacy Biller / Coder
• Patient Access Coordinator
• Revenue Cycle Manager (Pharmacy)

Career Advancement:

A CPBRS is positioned for leadership roles that directly impact the financial success of a pharmacy. They can advance to become a Director of Patient Access, a Director of Revenue Cycle, or a consultant for specialty pharmacies and health systems on reimbursement optimization strategies.

Study Resources

Prepare for your CPBRS exam with resources focused on the complexities of pharmacy reimbursement.