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

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