A health care benefit manager is a person or organization that provides services to or acts on behalf of a health carrier or employee benefits program. They can include specialized benefits, such as pharmacy, radiology, laboratory and mental health benefits.
Health care benefit managers offer services such as:
- Prior authorization or preauthorization of benefits or care
- Certification of benefits or care
- Medical necessity decisions
- Utilization reviews
- Benefit decisions
- Claims processing and repricing
- Outcome management
- Payment or payment authorization to providers and facilities
- Dispute resolution, grievances or appeals to benefit decisions
- Provider network management
- Disease management