Health Care Benefit Managers

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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

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