The r ole of the transplant nurse c ase m anager: How it w orks

1. The role of the transplant nurse case manager: How it works Tim Donovan, RN Transplant Case Manager, Optum Transplant Financial Coordinators Association Annual Workshop September 2017

2. Agenda United Health Group Introduction Transplant Nurse Case Management Transplant Authorization Processing Phases of the Transplant Process Continued Communications with Members and Providers Member Support and Guidance Authorization Updates/Renewals Optum Centers of Excellence & Transplant Closing – Q & A

3. Our culture A diversified enterprise with Complementary but Distinct Business Platforms Health Benefits Health Services Helping people live healthier lives and helping make the health system work better for everyone Our mission Our values

4. Transformation begins with relationships EMPLOYERS HEALTH PLANS PROVIDERS 300 4/5 4/5 CONSUMERS ofFortune 100 U.S. hospitals health plans GOVERNMENTS LIFE SCIENCES 115 million empowered consumers 100 34 organizations around the globe States, DC and many federal entities As of Q1, 2017

5. Achieving population health management CONSUMER ENGAGEMENT RIGHT TIME RIGHT PLACE DATA AND ANALYTICS CLINICAL SERVICES As of Q1, 2017

6. Optum Transplant Solutions national scale Transplants4 Transplant referrals4 Centers of Excellence3 Payer groups Member access 16,001 4,867 programs facilities million 159 60+ 14,297 870 Transplants per year Transplant referrals per year 179 when including Transplant Access Program (TAP) 1,270 total programswhen including TAP Total payer groups2 Members with access1 Sources: 1. McGillis, Zach. 2015 year-end UHC membership plus estimated external membership. Calculated August 23, 2016. 2. Michurski. Transplant Solutions Client groups in CMC Facets. August 2016. 3. Flies and Ruppert. Optum Transplant network status as of August 1, 2016. 4. McGillis. Count of 2015 cases created in CMC Facets. Accessed August 23, 2016.

7. Optum Transplant Solutions national scale • Today, Optum manages 16,000+ transplant referrals annually across the United States. Optum annual referrals and transplants Source: McGillis. Optum repriced claims data, CMC Facets. 2006–2015. Accessed August 2016.

8. Transplant nurse case management Authorization processing

9. RN Case Manager is the HUB Throughout the Process Transplant nurse case management Authorization processing: • Eligibility • Transplant Network Grid* • Transplant Request • Consult • Evaluation • Listing • Transplant Guidelines Referral From Provider or MD RN Transplant Case Manager • Authorization • #123456789 Authorization Approval • Transplant Network Grid Contains Listings of COE and TAP • Each COE and TAP is Approved for a Certain List of Transplant Types • Solid Organ • Stem Cell • Transplant • Medical Director Review • Denial Letter • Provider • Member Authorization Denial

10. Transplant Review Guidelines • Proprietary Transplant Review Guidelines are developed following extensive literature review in consultation with experts in the field and reviewed by the transplant expert panels in the following areas: Bone marrow/stem cell transplant Solid organ: Abdominal organ transplant Thoracic organ transplant • Our guidelines are revised annually • The most recent review was completed in September 2016

11. RN Case Manager is the HUB Throughout the Process Transplant nurse case management Authorization processing: • Eligibility • Transplant Network Grid* • Transplant Request • Consult • Evaluation • Listing • Transplant Guidelines Referral From Provider or MD RN Transplant Case Manager Authorization #123456789 Authorization Approval • Transplant Network Grid Contains Listings of COE and TAP • Each COE and TAP is Approved for a Certain List of Transplant Types • Solid Organ • Stem Cell Transplant Medical Director Review • Denial Letter • Provider • Member Authorization Denial

12. RN Case Manager is the HUB Throughout the Process Transplant nurse case management Our transplant program is designed to address the complex needs of our patients. For example: • Authorization • #123456789 Communication to Financial Transplant Case Manager Financial Case Manager Processes Patient’s Case • Authorization • #123456789 Authorization Approval • Transplant • Medical Director • Denial Letter • Provider • Member Communication to Financial Transplant Case Manager Appeal Process Peer to Peer • Continued Appeal Process* Authorization Denial Appeal Process is Clearly Explained on the Reverse Side of the Denial Letter

13. Communication with our providers’ financial case managers • Authorization requests should include the following components: • The request in writing. Can be as simple as a fax cover sheet. • Clinical information to support the need for the transplant.Contents of clinical information are different for each transplant phase: • Consult authorization • Evaluation authorization • Listing authorization • The requesting MD. • Your direct dial contact information and fax number. • Current member demographic information and phone number. Working together to streamline the authorization process

14. Provider fax form

15. Communication with our providers’ financial case managers • Authorization requests should include the following components: • The request in writing. Can be as simple as a fax cover sheet. • Clinical information to support the need for the transplant.Contents of clinical information are different for each transplant phase: • Consult authorization • Evaluation authorization • Listing authorization • The requesting MD. • Your direct dial contact information and fax number. • Current member demographic information and phone number. Working together to streamline the authorization process

16. Transplant nurse case management Stepping through the stages of the transplant process

17. Transplant case management: A different approach • Our transplant services deliver specialized transplant care coordinationplusaccess to our network of quality providers to create a more comprehensive solution that enhances the value and effectiveness of managed care programs. • Our solution include the following components: • Pre-screening process, to ensure appropriate treatment path • Specialized transplant care coordination • Access to Center of Excellence Network Maximize value by improving outcomes for patients.

18. Create, update and manage individualized care plan Additional BH/pharma review/consult as needed Comprehensive solution • Our transplant program is designed to address the complex needs of patients. • Each stage in the transplant continuum includes key objectives and activities instrumental to achieving optimal patient outcomes. For example: Referral & consultation (Stage 0) Transplant evaluation (Stage I) Pre-transplant (Stage II) Transplant procedure (Stage III) Early post-transplant (Stage IV) Late post-transplant (Stage V) • Transition of care into the program • Psychosocial assessment • Member outreach • Provider outreach • Assess transplant appropriateness through partnership with our COE facilities • Facilitation of alternative (non-transplant) care • Identification & management of unique cultural needs • Caregiver education • Coordination with client case manager • Coordination of care with existing providers • Utilization of client case managers as appropriate • Address barriers to care & patient compliance • Ongoing education of patient & caregiver • Review and update discharge plan & facilitate with program & caregivers • Ensure post-discharge pharmacy needs have been addressed & necessary medication will be available immediately upon discharge • Review discharge plan & revise as necessary • Collaboration with client/facility social worker to resolve gaps and give particular attention to caregiver needs • Ongoing medication review with particular attention to compliance & pharmacy issues; interventions as necessary • Transition care to primary care provider & client case manager

19. Case management and coordination of care process • Notification • Pre-transplant & • transplant Post-transplant • Dedicated Nurse Case Manager Assigned • Community & State Rate vs Optum URN or EC URN • Case set up in Optum’s case management platform • RN Performs Transplant Assessment • Confirm eligibility & review clinical • Network education • Barriers to care • Psych-social assessment • Consult with medical directors as appropriate • Provide evaluation recommendation to client • Approval/denial decision made - member and provider informed. • After listing, RN follows up with member every 1-3 months or as clinically necessary • Upon transplant, RN performs hospital stay utilization management for this admission and additional admissions up to one year post transplant. • RN works with transplant facility to coordinate the discharge plan • One year of follow up care is included in the transplant listing authorization • Office Visits • Labwork • RN coordinates discharge plan • Initial outreach 1-2 business days post-discharge • Follow up once/week for 1st month, bi-weekly in months 2 & 3 and monthly thereafter • Ongoing assessments & identification of care gaps • Barriers to care • Psych-social assessment • Member education • Medications • Transition of care and case closure - 365 days post-transplant From evaluation to post-transplant care, your members will benefit from our patient-centric care coordination model to address each member’s unique needs during every stage of the transplant.

20. From authorization request to one year post-transplant • Member Financial case manager • Building relationships • Continuity in care • Communication throughout the entire transplant process • Resource • Assistance in navigating the system • Authorization renewals • Initial contact and regular communications. • Resource – clinical, informational and psychosocial • Assistance in navigating the system • Continued assessment of needs • Social services • Behavioral health • Transportation issues • Psych-social assessment • Encourage compliance • Plan of care • Being there in times of need ■Integrity■Compassion■Relationships■Innovation■Performance

21. Accessing quality Centers of Excellence

22. The Optum Transplant network Designed for access and choice Access 78.6% of the U.S. population lives within 100 miles of a COE facility 97.1% of the U.S. population lives within 250 miles of a COE facility 99.9% of the U.S. population lives within 500 miles of a COE facility 159COE facilities* 104 COE facilities with public sector rates* Choice 100-mile radius 250-mile radius 500-mile radius • Transplant Facility Map source: Based on Optum COE network as of December 1, 2015 and the 2013 U.S. Census Population Estimate sample * Flies and Ruppert. Optum Transplant network status as of August 1, 2016. For a complete listing of the Optum COE network, please visit myoptumhealthcomplexmedical.com. Public sector rates refer to rates specific to Medicare Advantage and/or Managed Medicaid populations.

23. Centers of Excellence (COE) qualification • Optum dedicates more resources than any other organization in the nation to identify and qualify transplant programs as Centers of Excellence. Qualification resources Optum evaluates program volumes, outcomes, structure and processes. • Two internal dedicated medical directors • Two external associate medical directors • Six provider survey and analytics process managers • National SRTR database serving as basis for volume and survival criteria • Proprietary COE qualification criteria validated annually by expert panels • 18 of the nation’s leading surgeons make up three specialized annual external advisory panels • 654 transplant hospitals surveyed annually Solid organ programs are evaluated twice a year according to SRTR data releases. Each program is surveyed and evaluated on an annual basis. Note: NCQA has reviewed and certified Optum Credentialing and Utilization Management functions only. For complete details on the scope of this review, visit ncqa.org.

24. The COE survey collects data about: Volumes and outcomes/ national data Components of a quality program Patient selection and eligibility Physician/ surgeon experience Accreditations and certifications Program experience and stability Clinical research and publishing

25. COE qualification process Establish COE qualification criteria Optum Clinical Sciences Institute Review all transplant program qualification criteria with expert panels and Optum clinical experts Evaluate provider outcomes and processes Continuous quality improvement, including quality of care concerns, serious event processes, and member complaints Qualification decisions reviewed and approved by Policy Committee Conduct site visits (each facility visited minimally every 3-5 years, more often as needed)

26. Centers of Excellence drive better outcomes Clinical expertise and experience of the Transplant Centers of Excellence (COE) network lead to greater savings and cost avoidance In a population with almost 90% of our cases at COEs, our cases saw an average 17% lower hospital length of stay than the national benchmark1,2 That population experienced a 10% lower incidence than the national benchmark. COEs can avoid unnecessary and inappropriate transplants through: • Better diagnosis • More appropriate treatment identification1,2 Transplant incidence per 1M members 10% Transplants per 1M members Transplant inpatient days* 17% Inpatient days Sources: 1. McGillis and Ruppert. 2015 CMC Internal Claims Data for UHC FI (Facets). Accessed August 23, 2016. 2. Hanson S., Bentley T. 2014 U.S. organ and tissue transplant cost estimates and discussion. Milliman, Inc. http://www.milliman.com/uploadedFiles/insight/Research/health-rr/1938HDP_20141230.pdf. Published December 30, 2014. Accessed January 20, 2015. *Note: Length of Stay (LOS) includes days within the inpatient confinement period of a transplant episode. **Optum book of business LOS adjusted for transplant mix to match that of Mililman.

27. Thank you