Partners

Healthcare benefit managers

Effective January 1, 2022, health care benefit managers (HCBMs) will be required to register with the Washington State Office of the Insurance Commissioner (OIC).

What is a healthcare benefit manager?

Health care benefit managers (HCBMs) are defined as persons or entities providing services to or acting on behalf of, a health carrier, that directly or indirectly impact the determination or use of benefits for, or patient access to, health care services, drugs, and supplies. HCBMs include specialized benefit types such as pharmacy, radiology, laboratory and mental health. The services of an HCBM also include, but are not limited to:

• Prior- and pre-authorization of benefits or care: A mandatory process that an insurance carrier or its designated or contracted representative uses, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan. It occurs before the service is delivered.
• Certification of benefits or care: A certification is essentially a prospective medical review or a "pre-authorization" that a procedure is medically necessary. Failure to obtain a certification results in penalties, reductions in benefits, or both before any benefits are paid. A certification is also not a guarantee of payment.
• Medical necessity determinations: Those covered services and supplies that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or symptoms.
• Utilization review: Evaluation of the medical appropriateness and efficiency of the use of health care services, procedures, facilities, and medications to ensure safety, waste reduction, and cost containment.
• Benefit determinations: The processing of insurance claims or certain aspects of employee benefit plans on behalf of the plan sponsor or separate entity.
• Claims processing: A detailed request for payment filed by, or on behalf of, a customer.
• Outcome management: A collaborative service provided by licensed & certified clinicians with members, families, and practitioners to assess, plan, facilitate, care coordinate, evaluate, and advocate for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality and cost-effective outcomes.
• Provider credentialing: A formal process by which the Plan gives a Participating Medical Group or vendor the authority to perform certain functions on its behalf, while retaining accountability and responsibility for ensuring the function is performed appropriately.
• Payment or authorization of payment to providers and facilities: A formal process by which the Plan reimburses a provider or facility, in whole or in part, for a covered benefit under the plan.
• Dispute resolution, grievances, or appeals: Review of an Adverse Benefit Determination.
• Provider network management: A grouping of the individual facilities, providers, provider groups and suppliers the Company has a contractual agreement with to provide healthcare services.
• Disease management: An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education. It can improve quality of life while reducing health care costs of a member with a chronic disease by preventing or minimizing the effects of a disease.

What does this mean for me?

This is a new regulation for vendors or providers that are considered HCBMs. There are no changes to the services you receive as a member. If you still have questions, call the customer service number on the back of your card.

Who are LifeWise's healthcare benefit managers?