Optimum Healthcare implements and maintains Utilization Management (UM). The role of Utilization Management is to enable consistent delivery of appropriate and quality health care services to our members. UM functions include pre-certification, concurrent review, discharge planning, Complex Case Management and Disease Management.
The UM Department uses clinically sound, nationally developed and accepted criteria for making medical necessity decisions. This criterion includes, but is not limited to:
o Medicare National and Local Coverage Decisions
o State and Federal Statutes
o InterQual Criteria
o Hayes Medical Technology
UM decisions are based only on appropriateness of care and service, including existence of coverage. The Plan does not reward practitioners for issuing denials of coverage or care, and does not establish financial incentives for denial, limitation, or discontinuation of authorized services. For a copy of the UM Review Criteria, you may contact the UM department, Monday through Friday 8 a.m. to 5 p.m. at 1-888-796-0947.
Contacting the UM Department – Providers Only
The UM Department is available to speak with providers during normal business hours Monday through Friday 8 a.m. to 5 p.m. by calling 1-866-409-0888. The Plan’s Medical Director is available during business hours to discuss a UM decision with the treating physician and can be reached at the same number listed above. The UM Department is also available after business hours to all providers requiring urgent authorization assistance by calling 1-866-409-0888 which will connect them with the On-Call Nurse.