Bureau of Fee-for-Service Programs
Mission/Responsibilities: The Bureau of Fee-For-Service Programs (BFFSP) is the bureau within the Office of Medical Assistance Programs (OMAP) charged with the operational components of OMAP’s Fee-for-Service (FFS) healthcare delivery program to include the following:
- Provide medical review of services under FFS including prior authorization, program exception, and benefit limit exception for pharmacy, dental/orthodontic, and medical services (to include DME, Shift Nursing, home health, elective medical/surgical outpatient as well as inpatient services).
- Facilitate all phone and/or face to face recipient appeal hearings associated with these requests.
- Provide operational assistance to pharmacy providers, and inpatient/outpatient providers (to include physicians, DME, dental, home health, lab, & hospital providers) through outreach and communication, provider inquiry, and claims exceptions processing.
- Manage the pharmacy benefit through utilization management including the Preferred Drug List, prior authorization, drug use review, and specialty pharmacy.
- Review all inpatient and outpatient 180 day exception requests along with provider appeal hearings associated with these requests.
- Serve as liaison with the FFS Delivery System Subcommittee.
- Provide assistance to MA enrolled recipients concerning their benefits.
- Provide enrollment assistance to all providers wishing to enroll with MA for both the FFS and managed care delivery systems.
- Provide case management services to recipients with complex medical needs and catastrophic events.
- Assist individuals in need of one-on-one support with a registered nurse.