Operations Section (Benefits Coordination/Claims Processing)

  • Utilization Control and Claims Processing Unit Responsible for the utilization control, claims processing, and quality assurance; planning, development, implementation, monitoring, coordination, and evaluation of the utilization review/control and processing of medical claims, on-site reviews of institutional and non-institutional service providers, the development & monitoring of the service provider to include orientation; provider claims reconciliation.
  • Off-Island Referral Coordination Responsible for the coordination of off-island medical referrals.
  • Benefit Support Unit
  • Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) Responsible for the referral/authorization of the EPSDT Program services.
  • Buy-In Program (Medicare Entitlement) Responsible for the enrollment to the Medicare Buy-In Program for the eligible disabled and elderly Medicaid recipients.
  • Third-Party Liability Coordination Responsible for the coordination of the third-party liability of the Medicaid recipients.
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