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State Certified Networks

Managed Care Guidelines

Optum is certified as a Workers’ Compensation Managed Care Organization (MCO) in several states. For more information click on the state below.  

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DISCLAIMER
The state managed care organization information provided is for reference and general information purposes only. You should not rely on this material for making any business, legal or other decision. Optum makes no representations or warranties of any kind, express or implied, about the completeness, adequacy, validity or accuracy with respect to this information and any exclusive reliance you place on such material is at your own risk.

California

In the state of California, Optum provides access to two possible options for Medical Provider Network (MPN) services through our affiliate partners Anthem and Networks by Design in alignment with Administrative Regulations §9767.1-19.

The MPN includes access to a comprehensive network of providers specializing in the treatment of workers’ compensation injures, case management, utilization review, medical bill review, medical director oversight and dispute resolution. In addition to the standard MPN (Network Service Entity) offering, Custom MPN programs may be utilized, enabling control over specific aspects of the MPN.

We will coordinate with you and our network partners to review your options regarding the MPN, enabling us to find the solution that best fits the needs of your program and employer.

Employer

  • Access to the MPN allows for control over the medical direction throughout the life of the claim to in-network providers.
  • Coordinated care with Case Management team allows for seamless medical management and ensures all aspects of the MPN are being met and utilized to their fullest potential
  • Utilization Review system provided through our affiliate network guarantees the services provided are appropriate for the injured employee and are in accordance with medical practice standards
  • Dedicated quality team that focuses only on researching and resolving quality-related issues submitted through the dispute resolution/grievance procedure
  • Dedicated portal to help in direction of care guidance and in-network provider selection
  • Complimentary Provider Panels can also be provided

Employee

  • Choice of in-network providers and convenient geographic accessibility
  • Direct contact with the Case Management working on the claim
  • Assistance with understanding rules and requirements of the MPN

Connecticut

Optum is certified as a workers’ compensation managed care plan (MCP) in Connecticut. (Administrative regulations §31-279.10.)

The managed care plan includes access to a comprehensive network of providers specializing in the treatment of workers’ compensation injuries. The Plan also includes case management, utilization review, and medical bill review services with medical director oversight. A separate grievance and dispute process is also part of the plan.

The state of Connecticut requires employers to complete an Employer Participation Form to participate in the certified managed care program. This form is submitted to the Connecticut Workers’ Compensation Commission for review and approval. Optum assists with the preparation of the required state documents and submits all related documentation to the Connecticut Workers’ Compensation Commission.

In addition to the Employer Participation Form, the Connecticut Workers’ Compensation Commission requires each employer who has twenty-five or more employees per work location, as well as each employer who has twenty-four or fewer employees in Connecticut, and whose rate of work-related injury and illness exceeds the average incident rate, to establish and administer a safety and health committee for the work location separate from the information identified above.

Employer

  • Access to the MCP allows for control over the medical direction of the claim to in-network providers only
  • Coordinated care with Telephonic Case Management (TCM) and Field Base Case Management (FBCM) teams allows for seamless medical management and ensures all aspects of the MCP are being met and utilized to their fullest potential
  • Dedicated quality team that focuses only on researching and resolving quality-related issues submitted through the Optum grievance process
  • Dedicated provider portal to help in selecting providers for full in-network direction of care
  • Welcome packet that includes all state rules and required forms

Employee

  • Choice of in-network providers and convenient geographic accessibility
  • Direct contact with the TCM and FBCM working on the claim
  • Assistance with understanding rules and requirements of the MCP
  • Coordination of all medical supplies & equipment necessary through a central point of contact

GEORGIA

In the state of Georgia, Optum is certified* as a Workers’ Compensation Managed Care Organization (MCO) in alignment with Rule 208(a)(1).

The MCO includes access to a comprehensive network of providers specializing in the treatment of workers’ compensation injures, case management, utilization review, medical bill review, medical director oversight and dispute resolution.

Employer

  • Access to the MCO allows for control over the medical direction of the life of the claim to in-network providers
  • Coordinated care with Telephonic Case Management (TCM) team allows for seamless medical management and ensures all aspects of the MCO are being met and utilized to their fullest potential
  • A dedicated portal to help in direction of care guidance and in-network provider selection.
  • Complimentary Provider Panels can also be provided

Employee

  • The choice of in-network providers and convenient geographic accessibility
  • Direct contact with the TCM working on the claim
  • Assistance with understanding rules and requirements of the MCO
  • Coordination of all medical supplies and equipment necessary through a central point of contact (Requires use of the Optum Workers’ Comp and Auto No-fault Ancillary Prospective services)
*Certified in the following Geographic Service Areas: Appling, Atkinson, Bacon, Baldwin, Banks, Barrow, Bartow, Berrien, Bibb, Bleckley, Brantley, Appling, Atkinson, Bacon, Baker, Baldwin, Banks, Barrow, Bartow, Ben Hill, Berrien, Bibb, Bleckley, Brantley, Brooks, Bryan, Bulloch, Burke, Butts, Camden, Candler, Carroll, Catoosa, Charlton, Chatham, Chattahoochee, Chattooga, Cherokee, Clarke, Clay, Clayton, Cobb, Coffee, Colquitt, Columbia, Cook, Coweta, Crawford, Crisp, Dade, Dawson, Decatur, DeKalb, Dodge, Dooly, Dougherty, Douglas, Echols, Effingham, Elbert, Emanuel, Evans, Fannin, Fayette, Floyd, Forsyth, Franklin, Fulton, Gilmer, Glascock, Glynn, Gordon, Grady, Greene, Gwinnett, Habersham, Hall, Hancock, Haralson, Hart, Heard, Henry, Houston, Irwin, Jackson, Jasper, Jeff Davis, Jenkins, Johnson, Jones, Lamar, Lanier, Laurens, Lee, Liberty, Long, Lowndes, Lumpkin, Macon, Madison, McDuffie, Meriwether, Miller, Monroe, Montgomery, Morgan, Murray, Muscogee, Newton, Oconee, Paulding, Peach, Pickens, Pierce, Pike, Polk, Pulaski, Putnam, Quitman, Rabun, Richmond, Rockdale, Schley, Screven, Seminole, Spalding, Stephens, Stewart, Sumter, Talbot, Taliaferro, Tattnall, Taylor, Telfair, Terrell, Thomas, Tift, Toombs, Towns, Treutlen, Troup, Turner, Twiggs, Union, Upson, Walker, Walton, Ware, Warren, Washington, Wayne, Webster, Wheeler, White, Whitfield, Wilcox, Wilkes, Wilkinson, and Worth counties

Kentucky

Employer
 
  • Access to the Managed Health Care Plan (MHCP) allows for control over the medical direction of the claim to in-network providers only
  • Employees designate a physician who acts as a gatekeeper and coordinates all treatment with in-network providers
  • Coordinated care with Telephonic Case Management (TCM) and Field Based Case Management (FBCM) teams allows for seamless medical management and ensures all aspects of the MHCP are being met and utilized to their fullest potential
  • Dedicated quality team that focuses only on researching and resolving quality-related issues submitted through Optum’s grievance process
  • Dedicated portal to help in direction of care guidance and in-network provider selection
  • Welcome packet that includes all state rules and required forms

Employee

  • Choice of in-network providers and convenient geographic accessibility
  • Direct contact with the TCM working on your claim
  • Assistance with understanding rules and requirements of the MHCP
  • Coordination of all medical supplies and equipment necessary through central point of contact

Carrier

  • All state reporting required of the MHCP is done by Optum
  • TCM assistance with the medical management of the claim
  • Assistance with setting proper reserves on the file based on disability guidelines and recent treatment visit notes

Illinois

Optum is certified as a Workers’ Compensation Preferred Provider Plan (WCPPP) in Illinois. (Administrative regulations 820 ILCS 305/8.1a Article XX-1/2 §§370k, 370l, 370m, and 370p)

Employer

  • Access to the WCPPP allows for control over the medical direction of the claim to in-network providers who are skilled in the injury care, committed to the appropriateness and quality of treatment, and can get the injured employee back to work at the highest level of functionality
  • Provider can only refer WCPPP patients to an in-network facility or specialty
  • Coordinated care with Telephonic Case Management (TCM) team allows for seamless medical management and ensures all aspects of the WCPPP are being met and utilized to their fullest potential
  • Control costs and drive additional savings with increased provider accessibility
  • Welcome packet that includes all state rules and required forms

Employee

  • The choice of in-network providers and convenient geographic accessibility
  • Direct contact with the TCM working on the claim
  • Assistance with understanding rules and requirements of the WCPPP
  • Coordination of all medical supplies and equipment necessary through a central point of contact

New Jersey

Optum is certified as a Workers’ Compensation Preferred Provider Plan (MCO) in New Jersey. (Administrative regulations N.J.S.A. 34:15-1 et seq)

Employer

  • Access to the MCO allows for control over the medical direction of the claim to in-network providers who are skilled in the injury care, committed to the appropriateness and quality of treatment, and can get the injured employee back to work at the highest level of functionality
  • Coordinated care with Telephonic Case Management (TCM) team allows for seamless medical management and ensures all aspects of the MCO are being met and utilized to their fullest potential
  • Control costs and drive additional savings with increased provider accessibility
  • Welcome packet that includes all state rules and required forms

Employee

  • The choice of in-network providers and convenient geographic accessibility
  • Direct contact with the TCM working on the claim
  • Assistance with understanding rules and requirements of the MCO
  • Coordination of all medical supplies and equipment necessary through a central point of contact

New York

In the state of New York, Optum provides access to Certified Preferred Provider Organization (Certified PPO) services* through our affiliate partner MagnaCare in alignment with Administrative Regulations §325-8.

The Certified PPO includes access to a comprehensive network of providers specializing in the treatment of workers’ compensation injures, care coordination, utilization review, medical bill review, medical director oversight and dispute resolution.

We will coordinate with you and our network partners to review your options regarding the Certified PPO, enabling us to find the solution that best fits the needs of your program and employer.

Employer

  • Access to the Certified PPO allows for control over the medical direction for the first 30 days of the claim to in-network providers.
  • Access to Care Coordinators through our affiliate network allows for seamless medical management and ensures all aspects of the Certified PPO are being met and utilized to their fullest potential
  • Utilization Review system provided through our affiliate network guarantees the services provided are appropriate for the injured employee and are in accordance with medical practice standards
  • Dedicated quality team that focuses only on researching and resolving quality-related issues submitted through the dispute resolution/grievance procedure
  • Dedicated portal to help in direction of care guidance and in-network provider selection
  • Complimentary Provider Panels can also be provided

Employee

  • Choice of in-network providers and convenient geographic accessibility 24 hours a day, 7 days a week
  • Direct contact with the Care Coordinators working on the claim
  • Assistance with understanding rules and requirements of the Certified PPO
*Certified in the following Counties:
Albany, Bronx, Dutchess, Erie, Kings, Monroe, Nassau, New York, Niagara, Oneida, Onondaga, Orange, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Suffolk, and Westchester counties.
Claims in non-certified counties may utilize the Reccomendation of Care (RoC) Program, enabling employees to voluntarily select in-network providers.

West Virginia

In the state of West Virginia, Optum is certified as a Workers’ Compensation Managed Health Care Plan (MHCP) in alignment with Administrative Code W. Va. CSR § 85-21-4.

The MHCP includes access to a comprehensive network of providers specializing in the treatment of workers’ compensation injures, and additional services including case management, utilization review, medical bill review, dispute resolution, and medical director oversight.

Employer

  • Access to the MHCP allows for control over the medical direction of the life of the claim to in-network providers
  • Coordinated care with Telephonic Case Management (TCM) team allows for seamless medical management and ensures all aspects of the MHCP are being met and utilized to their fullest potential
  • Dedicated quality team that focuses on researching and resolving any network-related inquiries through the Optum dispute resolution/grievance procedure
  • A dedicated portal to help in direction of care guidance and in-network provider selection
  • Complimentary Provider Panels can also be provided
  • Welcome packet that includes all pertinent state rules and required forms

Employee

  • The choice of in-network providers and convenient geographic accessibility
  • Direct contact with the TCM working on the claim
  • Assistance with understanding rules and requirements of the MHCP
  • Coordination of all medical supplies and equipment necessary through a central point of contact