Health Care Benefit Managers
Learn about the health care benefit managers that support Molina Healthcare of Washington Marketplace and the services they provide to members.
| Entity Name | Service Provided |
|---|---|
| CaremarkPCS Health, LLC* |
Utilization review Benefit determinations Claims processing and repricing for services and procedures Outcome management Payment/authorization of payment to providers Pharmacy provider network management Dispute resolution Disease management |
| Firstsource Health Plans and Healthcare Services, LLC | Claims processing, including adjudication and adjustment |
| Molina Clinical Services, LLC |
Medical necessity determinations Utilization review Prior authorizations |
| Molina Healthcare, Inc. |
Prior authorization or preauthorization of benefits or care Certification of benefits or care Medical necessity determinations Utilization review Benefit determinations Claims processing and repricing for services and procedures Outcome management Payment or authorization of payment to providers and facilities for services or procedures Dispute resolution, grievances, or appeals relating to determinations or utilization of benefits Provider network management Disease management |
| Evolent Specialty Services, Inc. |
Prior authorization or preauthorization of benefits or care Utilization review |
| OptumInsight, Inc. |
Prior authorization or preauthorization of benefits or care Utilization review Benefit determinations Dispute resolution, grievances, or appeals relating to determinations or utilization of benefits Provider network management |
| Dane Street, LLC |
Independent peer review services Medical necessity determinations Utilization review Prior authorization or preauthorization of benefits or care |
| HealthMap Solutions Inc. | Disease management |
*CaremarkPCS Health, LLC is also considered a Health Care Benefit Manager for Molina Apple Health (Medicaid).
A health care benefit manager (HCBM) is any person or entity that provides services to or acts on behalf of a health carrier or employee benefits program. HCBMs directly or indirectly impact the determination or use of benefits for a patient access to health care services, drugs and supplies.
HCBMs include, but are not limited to, specialized benefit types such as pharmacy, radiology, laboratory and mental health.
The services of an HCBM also include:
Effective Jan. 1, 2022, health care benefit managers (HCBMs) will be required to register with the Washington state Office of the Insurance Commissioner (OIC).
For more information on health care benefit managers, please visit OIC website at Registering as a health care benefit manager (HCBM)