State certified networks

In the state of California, Optum offers 2 options for medical provider network (MPN) services, through our affiliate partners Anthem and Networks by Design, in alignment with Administrative Rules §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, we also provide custom MPN programs, which allow you to control specific aspects of the MPN.

Along with our network partners, we review and explain MPN options to help clients determine the solution that best fits the needs of their program and employers.

Benefits to employer

• Access to MPN allows control over medical direction, throughout life of claim, to in-network providers
• Coordinated care with Case Management team supports seamless medical management, and helps ensure that all aspects of MPN are met and utilized to their fullest potential
• Utilization Review (UR) system, provided through the Optum affiliate network, guarantees services provided are appropriate for injured employee and are in accordance with medical practice standards
• Dedicated quality team that focuses on researching and resolving quality-related issues submitted through dispute resolution / grievance procedure
• Dedicated portal that supports direction of care guidance and in-network provider selection
• Complimentary provider panels (if needed)

Benefits to employee

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

In the state of Connecticut, Optum is certified as a workers’ compensation medical care plan (MCP), in alignment with Administrative Regulation §31-279-10.

The MCP 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.

Connecticut requires employers to complete an Employer Participation Form to participate in the certified medical 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 25 or more employees per work location, as well as each employer who has 24 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.

Benefits to employer

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

Benefits to employee

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

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

The WC/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.

Benefits to employer

• Access to WC/MCO allows control over medical direction, throughout life of claim, to in-network providers
• Coordinated care with Telephonic Case Management (TCM) team supports seamless medical management, and helps ensure all aspects of MCO are met and utilized to their fullest potential
• Dedicated portal that supports direction of care guidance and in-network provider selection
• Complimentary provider panels (if needed)

Benefits to employee

• Choice of in-network providers and convenient geographic accessibility
• Direct contact with TCM staff working on claim
• Assistance with understanding MCO rules and requirements
• Coordination of all necessary medical supplies and equipment 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

In the state of Kentucky, Optum is certified as a workers’ compensation managed health care plan (MHCP), in alignment with Regulation 803 KAR 25:110.

Benefits to employer

• Access to MHCP allows control over medical direction, throughout life of claim, to in-network providers
• Employee-designated 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 supports seamless medical management and ensures all aspects of the MHCP are met and utilized to their fullest potential
• Dedicated quality team that focuses on researching and resolving quality-related issues submitted through grievance process
• Dedicated portal that supports direction of care guidance and in-network provider selection
• Welcome packet that includes all state rules and required forms

Benefits to 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 a central point of contact

Benefits to carrier

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

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

Benefits to employer

• Access to WCPPP allows control over medical direction, throughout life of claim, to in-network providers who are skilled in injury care, committed to appropriateness and quality of treatment, and can get injured employees back to work at 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 supports seamless medical management and ensures all aspects of the WCPPP are met and utilized to their fullest potential
• Ability to control costs and drive additional savings through increased provider accessibility
• Welcome packet that includes all state rules and required forms

Benefits to employee

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

In the state of New Jersey, Optum is certified as a Workers’ Compensation Preferred Provider Plan (MCO), in alignment with Administrative Regulations N.J.S.A. 34:15-1 et seq.

Benefits to employer

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

Benefits to employee

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

In the state of New York, Optum provides 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.

Along with our network partners, we review and explain Certified PPO options to help clients determine the solution that best fits the needs of their program and employers.

Benefits to employer

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

Benefits to employee

• Choice of in-network providers and convenient geographic accessibility 24 hours a day, 7 days a week
• Direct contact with care coordinators working on claim
• Assistance with understanding Certified PPO rules and requirements

*Optum is 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 Recommendation of Care (RoC) Program, enabling employees to voluntarily select in-network providers.

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.

Benefits to employer

• Access to MHCP allows control over medical direction, throughout life of claim, to in-network providers
• Coordinated care with Telephonic Case Management (TCM) team supports seamless medical management and ensures all aspects of the MHCP are 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
• Dedicated portal that supports direction of care guidance and in-network provider selection
• Complimentary provider panels (if needed)
• Welcome packet that includes all pertinent state rules and required forms

Benefits to employee

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