As a managed care company, Optum is tasked with supporting covered members by providing clinical risk and utilization management. Optum created the ALERT program to facilitate clinical risk and utilization management for routine outpatient treatment where no pre-authorization is required.
Our goal is to reduce the administrative burden on providers, while also ensuring quality and efficient treatment for our members by identifying cases where a clinical discussion between Optum and the treating provider may improve the quality of care, reduce clinical risk or reduce over-utilization of services. Through this engagement strategy, up to 90% of all routine outpatient treatment episodes require no interaction between Optum and the provider.
Optum uses clinical and claims data to identify cases where interaction between Optum and the treating provider is likely to improve quality of care, adherence to evidence-based care, and care outcomes. The data comes from submitted Wellness Assessments, behavioral claims, and pharmacy claims. This approach to reviewing patterns of care allows the vast majority of outpatient cases to proceed without any interaction between Optum and the treating provider.
Interventions by Optum are initiated by letter and/or phone call to the treating provider. Optum staff personnel reviewing the clinical and claims data are licensed clinicians.
*NOTE: For self-funded and fully insured commercial health plans, for which behavioral health and/or substance use disorder benefits are administered by Optum:
- ALERT no longer results in partial or full denials for coverage or payment