Health Care Benefit Manager
Molina Healthcare of Washington
2025 Marketplace
|
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. |
Payment integrity including subrogation and resolution services |
| 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 |
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 or 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:
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
Provider credentialing and re-credentialing
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
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 https://www.insurance.wa.gov/registering-health-care-benefit-manager-hcbm
Find helpful resources, plan materials, payment information and more.
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