Health Care Benefit Managers

Health Care Benefit Manager
Molina Healthcare of Washington
2024 Marketplace

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