Optum™ Documentation

Martin’s Point regularly evaluates our medical policies, clinical programs and health benefits based on the latest scientific evidence to help ensure our member benefit coverage is medically appropriate. We are choosing to implement Optum, as part of our commitment to working with care providers to help support improved population health outcomes, affordable evidence-based treatment, and leverage Optum’s expertise in the oncology and specialty fields.

This FAQ information is available to anyone. Detailed training videos and instructional handouts are accessible once you have logged into the Provider Portal.

All providers and staff who currently have access to Martin’s Point Provider Portal will be able to enter an authorization through the Optum platform.

If your organization does not current have a local administrator for the Martin’s Point Provider Portal but would like to have access to Optum, please follow this link to register for access: https://martinspoint.org/account/register

Once you are logged in, you can visit our Change Password page.

For other user functions, please see our provider portal user guide found under System Documents at the Forms and Documents page.

If you are having trouble logging in, please visit the Forgot username or Forgot password page.

For other user functions, please see our provider portal user guide found under System Documents at the Forms and Documents page.

No, for security purposes every user will have their own username and password.

Chrome offers the best user experience, but Internet Explorer is also compatible.

You can find draft and completed (submitted) prior authorizations on the homepage of the Optum UM portal. In-progress authorizations can be saved as a draft at any time during the authorization process. Submitted authorizations will have a final decision displayed when the case has been reviewed and decisioned.

You’ll need one of the following combinations to search for an authorization:

• Draft Search: Provider tax identification number (TIN), member ID number,
• History Search: Provider TIN, member ID number, and name
• Submitted Search: Member ID number

Optum Medical Oncology services (Cancer Guidance Program) authorizes selected outpatient IV/infusion chemotherapy/systemic therapy, supportive care therapies and therapeutic radiopharmaceuticals for in scope members under the medical benefit. The prior authorization requirements and guidelines can be found on the Martin’s Point website.

The Radiation Oncology Program, as part of the Cancer Guidance Program, authorizes certain radiation therapy services for in-scope members being treated in an outpatient setting. The prior authorization requirements and guidelines can be found on the Martin’s Point website.

This requirement includes the following radiation therapy modalities and services:

• Intensity-modulated radiation therapy (IMRT)
• Proton beam therapy (PBT)
• Stereotactic body radiation therapy (SBRT), including stereotactic radiosurgery (SRS)
• Image-guided radiation therapy (IGRT)
• Special and associated services (e.g., dosimetry and special physics consults, which are reflected in the codes in the appendix of this presentation)
• Fractionation using IMRT, PBT, and Standard 2D/3D radiation therapy for prostate, breast, lung, and bone metastasis cancers
• Selective internal radiation therapy (SIRT), Yttrium 90 (Y90) and implantable beta-emitting microspheres for treatment of malignant tumors

Optum Specialty Drug (Specialty Guidance Program) authorizes non-oncology Part B drugs across over 50 conditions for in scope members under the medical benefit. The prior authorization requirements and guidelines can be found on the Martin’s Point website.

This requirement includes the following drug classes:

• Anemia
• Blood Modifiers
• Botulinum Toxins
• Central Nervous System Agents
• Enzyme Deficiency
• Immune Globulin
• Immune Modulator
• Inflammatory Agents
• Neutropenia
• Sodium Hyaluronate
  • Please see the Martin’s Point website for a complete list as changes may occur throughout the year

Prior authorization for in-scope drugs and services will be required for all Generations Advantage Medicare plans:

• GA Alliance (HMO)
• Value Plus (HMO)
• Prime (HMO-POS)
• Focus DC (HMO SNP)
• Select (LPPO)

Optum will not be managing prior authorization requests for our US Family Health Plan (TRICARE Prime) members.

No, predeterminations will not be processed by Optum. Please call 1-888-732-7364 for specific questions on prior authorization requirements.

The prior authorization request is valid for ninety (90) days for approved radiation therapy services.

The prior authorization request is valid for non-oncology and medical oncology drugs based upon the drug/regimen selected.

Receipt of a prior authorization does not guarantee claim payment. Payment for covered services is contingent upon the member’s eligibility on the date of the service, billing (coding) reimbursement policies, and the terms of your contract.

If you do not obtain prior authorization for required services, your claim will be denied for lack of prior authorization.

For members INITIATING treatment on or after March 1, 2023, if prior authorization is not obtained your claims will be denied. (Prior authorization is not required for members who have started radiation services prior to March 1, 2023. If treatment goes beyond June 30, 2023, prior authorization will be needed for dates of service on or after July 1, 2023.)

Please complete all prior authorization requests online using the Optum UM portal, or by calling 866-572-9491, 8:00am - 8:00pm ET, Monday through Friday

1. Access the system – Navigate to the Authorizations webpage, select “Optum” and sign into the Provider Portal with your credentials
2. Input clinical data – The system will prompt you to provide clinical information during the intake process
3. Rapid decision – If the clinical criteria are met, you will receive an “approved” decision at or near the time of submission
4. If needed, peer-to-peer review – To help ensure we have all the information we need to provide an accurate coverage determination, we may contact you
5. Authorization status – Access Optum’s tool for auth status at all stages. Decisioned authorizations will be viewable in TruCare ProAuth.

If you have an active (non-expired) authorization before March 1, 2023, you don’t need to get a new authorization. The authorization will remain active until it expires.

No, at this time the only medications included in the tool are those that would be covered under Part B (paid under the medical benefit). For Medicare Part D requests, the user will be prompted to contact the patient’s PBM.

Call 1-866-572-9491 or email: [email protected] or [email protected].

You can call Provider Inquiry at 1-888-732-7364.

Call Optum at 866-572-9491 and a team member will assist you with submitting an authorization.

Call Optum at 866-572-9491 and a team member will assist you.

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