Operations Section (Benefits Coordination/Claims Processing)

1. Utilization Control and Claims Processing Unit

Responsible for the utilization control, claims processin, 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.

2. Off-Island Referral Coordination

Responsible for the coordination of off-island medical referrals.

3. 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.