Case Management and Disease Management Program Information, Preferred Care Partners - 2020 UnitedHealthcare Administrative Guide

Case Management and Disease Management Program Information

Optum provides Case Management (CM) and Disease Management (DM) services for Preferred Care Partners.

Below is the criteria for referrals to Optum CM and DM Programs:

  • Complex Case Management — (Special Needs Plan [SNP] members only)
    • Three or more unplanned admissions and/or emergency room (ER) visits in the last six months or
    • Multiple, complex co-morbid conditions and/or
    • Coordination of multiple community resources/ financial supports to cover basic service.
  • Heart Failure (HF) Disease Management Program
    • Diagnosis of HF and
    • Has CHF on an inpatient claim or
    • HF admission in last three months
  • Diabetes Disease Management Program
    • Diabetic with A1C 9% or greater or
    • An inpatient admission related to diabetes in the past 12 months or
    • Two or more ER visits related to diabetes
  • Advanced Illness Case Management — The primary goal is to facilitate and support end-of-life wishes and services
    • Life expectancy of 12-18 months
    • Chronic, irreversible disease or conditions and declining health
    • Reduce disease and symptom burden
  • Transplant Case Management and Network Services
    • Bone marrow/stem cell, including chimeric antigen receptor T-Cell (CAR-T) therapy for certain hematologic malignancies, kidney and kidney/pancreas, heart, liver, intestinal, multi-organs and lung transplants
    • Case management for one year post-transplant
  • End-Stage Renal Disease Case Management — The member is diagnosed with end-stage renal disease and is undergoing outpatient dialysis including in-center or home hemodialysis, home peritoneal dialysis, etc.

If the member does not qualify for one of these programs, they have 24/7, 365 days a year access to speak with a nurse by calling the Optum NurseLine number on the back of their ID card.

NOTE: South Florida Preferred Care Partners no longer provides social worker evaluations without skilled services. Please direct your patient to their local social services department or the Florida State Department of Elder Affairs Help Line at 800-963- 5337.

To request CM or DM services for one of our members, select only one program based on the program criteria that most closely matches the member’s medical condition. Then submit the CM/DM referral form, available on, to

Behavioral Healthcare Programs

We work with Optum Behavioral Health to provide behavioral health care services for our members. For more information on how to access the Behavioral Healthcare programs, you or our members may contact a representative through the phone number listed on the back of their health care ID card.