Information on utilization management
Affirmative statement regarding incentives
The OptumCare® core values of integrity and compassion dictate that we deliver the most effective care possible to every patient.
This principle should be the guiding force behind all the decisions we make when it comes to patient care, including those surrounding utilization management.
Therefore, we are sharing this affirmative statement about incentives (specifically relating to utilization management).
- Utilization management (UM) decisions are made using nationally recognized criteria. UM decision-making is based only on appropriateness of care and services, and the existence of coverage.
- OptumCare does not reward practitioners or other individuals for issuing denials of coverage.
- Financial incentives for UM decision-makers do not encourage decisions that result in underutilization. Nor are incentives used to encourage barriers to care and service.
- Hiring, promoting or terminating practitioners or other individuals is not based upon the likelihood or the perceived likelihood that the individual will support or tend to support the denial of benefits.
As an OptumCare contracted provider or employee, you are responsible for ensuring that any UM decisions you make adhere to the guidelines above. If you have any questions, we are happy to assist.
Please call our UM department
1-877-370-2845, TTY 711 for hearing impaired
8 a.m.–5 p.m., Mon–Fri
How to obtain UM criteria
OptumCare always applies objective, evidence-based criteria and takes individual circumstances into account when determining the medical appropriateness of health care services. We use several criteria when making decisions on utilization management (UM).
These include health plan policies, CMS criteria and the Milliman Care Guidelines.
Providers are welcome to call us at any time to obtain a copy of these UM criteria. When a request is made for UM criteria, information not available on a website will be sent to the provider via fax or secure email.
To obtain a copy of our UM criteria please call our UM department at the number listed in the ‘UM Communication Services’ section below. OptumCare may use UnitedHealthcare Medicare Coverage Summaries.
You may also obtain copies of this criteria on their website below.
How to request review for UM denials
It is our policy to make an appropriate medical director available to discuss UM denial decisions. The attending physician may always request a peer-to-peer conversation with the medical director who completed the UM review.
Please do this by calling the phone number listed in the ‘UM Communication Services’ section. A UM representative will collect your contact information and pass it along to the medical director who issued the denial decision.
The medical director will contact you directly to initiate the conversation. Please note: only the attending physician may request review of UM denials.
UM Communication Services
OptumCare provides access to staff for members and providers seeking information about the UM process and the authorization of care. We are happy to answer any questions you may have. You can reach our UM department at the phone number below.
877-370-2845, TTY 711 for hearing impaired
8 a.m.–5 p.m. MST, Mon–Fri
Language assistance is available upon request.
If you would like to obtain specific information about a pending UM request, please have the patient name and member number ready. Once you provide these details, any of our staff can assist you.
Our staff is also able to receive communications and questions regarding UM issues outside of normal business hours. Providers can leave a voice mail message at the number above; they can also send UM inquiries via the provider web portal.
To access the portal, log in via any page on the provider website. Below the Log In prompt is a link to create a new account if the provider does not yet have access to the portal.
Once logged in, select ‘Contact Us’ from the left-hand menu and choose the ‘Secure Message Center’ link.
Please indicate provider name and contact information in all after-hours messages. If the request applies to a specific patient, please also indicate the patient name and member number if available.
All messages regarding UM that are received after normal business hours will be returned the next business day.
Our staff has the ability to send outbound communication and return all messages during normal business hours.
When you call the UM information line, the representative assisting you will identify themselves by name, title and organization. Representatives sending outbound communication regarding UM will also always identify themselves.
Out-of-area callers can obtain information by using the same toll-free number listed above. In addition, we are able to accept collect calls regarding UM issues.