Important Communication

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What is Optum’s Complex Case Management Program?

Optum offers a Complex Case Management program for individuals who could be helped through more intensive coordination of services. This program is intended to help people with complex behavioral health conditions connect with needed services and resources. Behavioral Health Advocates work intensely with you or your loved one in the development of a comprehensive plan of care which coordinates the following:

• Therapeutic services (therapy, medication management, case management, etc.)
• Community and Psychosocial supports (education/support regarding illness, coordination with support system, other supportive services)- Coordination of care between medical and behavioral physicians and clinicians
• Recovery and Resiliency Services (peer support, development of a crisis/recovery plan, life planning activities)
• Other services as appropriate (legal, shelter, basic needs, etc.)

Program Goals:

• Movement to recovery
• Enhanced wellness
• Building resiliency through self-care and empowerment

Criteria for acceptance into the program include:

• Presence of complex behavioral health condition(s) which require a greater level and intensity of services
• History of intensive behavioral health service utilization over the past 12 months
• Willingness to actively participate in the program for at least 90 days

If you believe that you or a loved one meet these criteria and would benefit from Optum’s Complex Case Management program, please contact Optum via the toll-free number on the back of the member’s insurance card to ask for this program. Optum looks forward to partnering with you or your loved one on the path to recovery and wellness.

What are my rights and responsibilities?

1. Members have a right to receive information about the organization, its services, its network clinicians, and members’ rights and responsibilities. 2.) Members have a right to be treated with respect and recognition of their dignity and right to privacy. 3.) Members have a right to participate with network clinicians in making decisions about their health care.
2. Members have a right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
3. Members have a right to voice complaints or appeals about the organization or the services it provides.
4. Members have a right to make recommendations regarding the organization’s members’ rights and responsibilities policies.
5. Members have a responsibility to supply information (to the extent possible) that the organization and its network clinicians need in order to provide care.
6. Members have a responsibility to follow plans and instructions for care that they have agreed on with their network clinicians.
7. Members have a responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
8. Members have a right to care that is considerate and that respects their personal values and belief systems.
9. Members have a right to personal privacy and confidentiality of information.
10. Members have a right to reasonable access to care, regardless of race, religion, gender, sexual orientation, ethnicity, age, or disability.
11. Members have a right to have their family members participate in treatment planning. Members over 12 years old have the right to participate in such planning.
12. Members have a right to individualized treatment, including:

• Adequate and humane services regardless of the source(s) of financial support.
• Provision of services within the least restrictive environment possible.
• An individualized treatment or program plan.
• Periodic review of the treatment or program plan.
• An adequate number of competent, qualified, and experienced professional clinicians to supervise and carry out the treatment or program plan.

15. Members have a right to participate in the consideration of ethical issues that arise in the provision of care and services, including:

• Resolving conflict.
• Withholding resuscitative services.
• Forgoing or withdrawing life-sustaining treatment.
• Participating in investigational studies or clinical trials.

16. Members have a right to designate a surrogate decision-maker if the member is incapable of understanding a proposed treatment or procedure or is unable to communicate his or her wishes regarding care.
17. Members and their families have a right to be informed of their rights and responsibilities in a language they understand.
18. If a member chooses not to comply with recommended care, treatment, or procedures, the clinician is to inform the member of the potential consequences of not complying with the treatment recommendations.
19. Members have a right to be informed of rules and regulations concerning their own conduct.
20. Members have a right to be informed of the reason for any adverse determination, including the specific utilization review criteria or benefit provisions used in the determination.
21. Members have a right to have utilization management decisions made based on appropriateness of care. The organization does not reward network clinicians or other individuals conducting utilization review for issuing adverse determinations for coverage or service.
22. Members have a right to:

• Inspect and copy their protected health information (PHI).
• Request to amend their PHI.
• Request an accounting of non-routine disclosures of PHI.
• Request limitations on the use or disclosure of PHI.
• Request confidential communications of PHI to be sent to an alternate address or by alternate means.
• Make a complaint regarding use or disclosure of PHI.
• Receive a Privacy Notice.

23. Members have a right to receive information about the organization’s clinical guidelines and Quality Improvement program.

How we make decisions about benefit coverage

All our staff follow strict rules when they decide about approval of benefits. Decisions are based on what your benefits cover and your medical need. We do not reward staff or healthcare providers for saying “no” to care or service. We do not give financial rewards to our staff or healthcare providers to make decisions that result in less care or service than what is needed.

How to contact us

Our offices are open Monday through Friday. Our hours are from 8 a.m. to 5 p.m., except on holidays. You can call the toll-free number on your insurance card or health plan member ID card to learn about your benefits or get approval for care. Optum offers language assistance, at no added cost for members who prefer to speak a language other than English. Our offices have toll-free numbers for members with hearing impairments. You can also get help with services or ask questions. A Care Advocate can answer your questions about services and our decisions. Our staff will tell you their name, title, and where they work.

If you have an emergency or urgent health concern, seek immediate attention or call 9-1-1. You can always contact one of our Care Advocates 24 hours a day, 7 days a week. You can even speak to a Care Advocate on weekends and holidays. To call us, use the toll-free number on your health insurance card or health plan member ID card or in your benefits booklet or Evidence of Coverage.