Fee For Service Management

The Division of Fee-For-Service Management (DFSM) oversees clinical, administrative, and claims operations for over 250,000 Fee-For-Service (FFS) members, including American Indians/Alaska Natives, Tribal ALTCS members, and individuals in the Federal Emergency Services population.

Key Responsibilities:

• Claims & Clinical Services: Processes provider claims, authorizes services, reviews clinical claims, investigates quality of care issues, and coordinates care for FFS members.
• Provider Support: Offers training and technical assistance to FFS providers.
• Third Party Administration: Manages programs like:
• School-Based Claiming
• Pharmacy Benefit Manager (Optum)
• County Department of Corrections accounts

Tribal Oversight & Programs:

• TRBHA Oversight: Manages Intergovernmental Agreements with five Tribes for behavioral health coordination, covering over 100,000 members.
• American Indian Medical Home (AIMH): Oversees agreements with IHS/Tribal 638 facilities to provide primary care case management and coordination for AIHP members.