ALERT® - Algorithms for Effective Reporting and Treatment

As a managed care company, Optum is tasked with supporting covered members by providing clinical risk and utilization management. Clinical risk and utilization management for routine outpatient treatment necessitates a special process because that level of care usually does not require pre-authorization. Optum created the ALERT program to facilitate clinical risk and utilization management for routine outpatient treatment where no pre-authorization is required.

The goal of the Alert program is to facilitate clinical discussion between Optum and the treating provider where such discussion is likely to be impactful. This approach reduces provider administrative burden on cases where interaction between Optum and the treating provider is less likely to have an impact. About 90% of all routine outpatient treatment episodes require no interaction between Optum and the provider.

ALERT works by using clinical and claims data to identify outlier cases where interaction between Optum and the treating provider is likely to add value.  The data comes from submitted Wellness Assessments, behavioral claims, and pharmacy claims. This approach allows the vast majority of outpatient cases to proceed without any interaction between Optum and the treating provider.

ALERT interventions are initiated by letter and/or phone call to the treating provider. Optum ALERT intervention staff are licensed clinicians.