Managed care at Optum

PPO

Hospital and physician expenses present significant opportunity for savings. Through a combination of national affiliations, and regional and proprietary networks, our PPO network service:

  • Ensures seamless access to experienced, credentialed providers
  • Delivers savings through assertive contract negotiations
  • Includes rigorous credentialing standards and persistent monitoring of provider qualifications and performance
  • Prospectively applies treatment protocols from the inception of medical treatment
  • Provides reliable, actionable PPO network data

Many PPO networks can produce high penetration rates and savings. Only we have the quality of network, data integrity and processes to increase savings, simplify administration and improve outcomes, both clinically and financially.

Medical Bill Review

When it comes to medical bill review, our technology is only half the story. Our knowledgeable and experienced in-house professionals leverage data and automated processes to complete timely, accurate, professional-level clinical reviews. As a result, clients realize maximum savings as the medical bill review process:

  • Combines national coverage capabilities with regional networks
  • Applies national coding parameters
  • Detects improper billing practices and duplicate entries
  • Integrates all utilization review decisions into the medical bill review process

And to make sure the program best suits your unique needs, like many of our programs, medical bill review services can be integrated with other products, such as PPO and specialty networks or provided on a stand-alone basis.

Case Management

Starting with the first report of injury, our case management program, which includes telephonic, field and vocational assessments, establishes a claimant advocate who coordinates and channels care, where permitted, with accessible and experienced network providers. This helps to make certain medical treatment is:

  • Managed proactively based on recognized medical guidelines and evidence-based medicine
  • Safe, cost-effective and designed to promote recovery
  • In accordance with program parameters and jurisdictional regulations
  • Compassionate and well-coordinated to alleviate concerns and promote adherence
Want to know more? Click here.

NJ Auto Pre-Certification

Our auto injury management service (AIMS) adheres to the New Jersey Automobile Insurance Cost Reduction Act of 1998 (AICRA). The Act requires practitioners to provide notification of intended medical procedures, treatments, diagnostic tests or other services, non-medical expenses and durable medical equipment.

Through the prospective review of medical treatment and procedures, Optum medical professionals review treatment plans submitted by providers to determine whether the policyholder is receiving the appropriate level of medical care, and whether the treatment plan is medically necessary. The pre-certification process includes the use of prior authorization, utilization review and case management protocols to ensure services are authorized in accordance with standard professional treatment guidelines.  

Optum AIMS professionals are experts in auto injury claims management, including case management, nursing, pharmacy and ancillary healthcare services. The AIMS team manages the entire pre-certification process including appeals and dispute resolution. 

This program is designed as a turn-key solution for auto carriers in adherence of AICRA regulations. Auto carriers utilize Optum to manage their pre-certification program because of our expertise in personal injury protection (PIP) and auto injury claims.   

Contact an Optum representative to learn more about our NJ Auto Pre-Certification program.



FileTypeSizeUploaded onDownload
Allstate DPR PlanPDF79.73 KB05 Jun, 2017 Download
The Cincinnati Insurance Company DPR PlanPDF73.19 KB05 Jun, 2017 Download
Utica DPR/Pre-cert PlanPDF92.91 KB05 Jun, 2017 Download
NL&F DPR PlanPDF84.77 KB05 Jun, 2017 Download
The Cincinnati Indemnity Company DPR PlanPDF73.17 KB05 Jun, 2017 Download
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MIC General Insurance Corporation DPR PlanPDF78.42 KB05 Jun, 2017 Download
NGIC DPR PlanPDF75.62 KB05 Jun, 2017 Download
Metromile Insurance Company DPR PlanPDF73.52 KB05 Jun, 2017 Download
Maidstone Insurance Company DPR PlanPDF143.47 KB05 Jun, 2017 Download
The Cincinnati Casualty Company DPR PlanPDF73.16 KB05 Jun, 2017 Download
Amtrust DPR PlanPDF144.92 KB05 Jun, 2017 Download
Kemper DPR PlanPDF279.88 KB05 Jun, 2017 Download
Esurance DPR/Pre-cert PlanPDF87.82 KB05 Jun, 2017 Download
Integon Insurance Company DPR PlanPDF73.23 KB05 Jun, 2017 Download
Metromile DPR PlanPDF78.40 KB05 Jun, 2017 Download
Farm Family DPR/Pre-cert PlanPDF84.95 KB05 Jun, 2017 Download
Attending Provider Treatment PlanPDF343.84 KB05 Jun, 2017 Download
Knightbrook DPR PlanPDF152.39 KB05 Jun, 2017 Download
Nova Casualty DPR/Pre-cert PlanPDF102.22 KB05 Jun, 2017 Download
Topa Insurance Company DPR PlanPDF143.89 KB05 Jun, 2017 Download

Effective February 15, 2013 Farmers Insurance Exchange and its affiliates will be a new client of the MagnaCare/Procura NY network for auto injury claims.