ALERT - Service Based Algorithms
Optum is tasked with providing utilization management for routine outpatient care where no pre-authorization is required. ALERT utilization management focuses on identifying cases where treatment length or frequency is higher than average. Members with higher treatment frequency or length often have complex clinical needs. The purpose of ALERT utilization management processes is to ensure that covered members are receiving all necessary care efficiently.
As with all ALERT algorithms, the goal of the ALERT utilization management program is to trigger a discussion between Optum and the treating provider for those cases in the outside the normal range of utilization. Up to 90% of all routine outpatient cases proceed forward without any interaction between the treating provider and Optum ALERT staff.
When ALERT identifies a case has having high or frequent utilization, a licensed ALERT clinician will call the treating provider to initiate a clinical case discussion. These discussions are designed to be collaborative, with the purpose of ensuring that the member is receiving appropriate and effective services.
In situations where treatment does not appear to meet the Optum level of care/coverage guidelines, ALERT staff will schedule a conversation between the treating provider and an Optum licensed peer reviewer. Based on member clinical needs and Optum guidelines, the peer review discussion may result in continued payment of services or in a partial or full denial for further routine outpatient treatment.