List of Optum Prospective Payment Customers
Eden Prairie, 55344, MN,
United States
Since 2010, our global team of researchers has been studying Optum Prospective Payment customers around the world, aggregating massive amounts of data points that form the basis of our forecast assumptions and perhaps the rise and fall of certain vendors and their products on a quarterly basis.
Each quarter our research team identifies companies that have purchased Optum Prospective Payment for Insurance Claims Management from public (Press Releases, Customer References, Testimonials, Case Studies and Success Stories) and proprietary sources, including the customer size, industry, location, implementation status, partner involvement, LOB Key Stakeholders and related IT decision-makers contact details.
Companies using Optum Prospective Payment for Insurance Claims Management include: Avera Health, a United States based Healthcare organisation with 22100 employees and revenues of $285.00 billion, Blue Cross Blue Shield of Michigan, a United States based Insurance organisation with 9500 employees and revenues of $36.30 billion, WellSense Health Plan, a United States based Insurance organisation with 1000 employees and revenues of $900.0 million, Health Plan of San Joaquin, a United States based Healthcare organisation with 480 employees and revenues of $85.0 million and many others.
Contact us if you need a completed and verified list of companies using Optum Prospective Payment, including the breakdown by industry (21 Verticals), Geography (Region, Country, State, City), Company Size (Revenue, Employees, Asset) and related IT Decision Makers, Key Stakeholders, business and technology executives responsible for the software purchases.
The Optum Prospective Payment customer wins are being incorporated in our Enterprise Applications Buyer Insight and Technographics Customer Database which has over 100 data fields that detail company usage of software systems and their digital transformation initiatives. Apps Run The World wants to become your No. 1 technographic data source!
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| Logo | Customer | Industry | Empl. | Revenue | Country | Vendor | Application | Category | When | SI | Insight |
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Avera Health | Healthcare | 22100 | $285.0B | United States | Optum | Optum Prospective Payment | Insurance Claims Management | 2025 | n/a |
In 2025 Avera Health implemented Optum Prospective Payment in an Insurance Claims Management context, placing the application into active use for claims pricing and adjudication at Avera Health Plans in the United States. The deployment centers on prospective payment tooling to govern DRG and APC logic as part of the health plan claims and finance workflow.
Optum Prospective Payment is operationalized through Optum EASYGroup for pricing configuration and adjudication logic, with configuration artifacts and rulesets aligned to DRG and APC-based prospective pricing. Functional capabilities in use include pricing configuration, claims adjudication rules, and DRG/APC logic maintenance, reflecting standard Insurance Claims Management workflows for prospective payment determination.
Operational coverage is explicitly within the claims and finance work area of Avera Health Plans, with an ongoing, role-based configuration model. A Payment Configuration Analyst position is listed as responsible for maintaining DRG and APC logic inside Optum EASYGroup, indicating a staffed governance model that embeds configuration control, compliance alignment, and ongoing rule maintenance into daily operations.
Governance and process control are structured around the Payment Configuration Analyst duties, which implies formal ownership for pricing logic updates, configuration testing, and compliance checks within Optum EASYGroup. The presence of this operational role demonstrates that Optum Prospective Payment is not a pilot but an active production component of the plan level Insurance Claims Management stack.
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Blue Cross Blue Shield of Michigan | Insurance | 9500 | $36.3B | United States | Optum | Optum Prospective Payment | Insurance Claims Management | 2024 | n/a |
In 2024 Blue Cross Blue Shield of Michigan engaged Optum Prospective Payment to provide commercial DRG claim audit and payment integrity support beginning June 2024. The Optum Prospective Payment deployment is recorded under the Insurance Claims Management category and is focused on validating inpatient DRG coding and reimbursement across commercial lines of business.
The implementation centers on DRG and prospective payment methodologies, leveraging capabilities consistent with Optum PPS and EASYGroup to support payment integrity and claim pricing work. Configuration emphasis included prospective payment pricing logic, DRG audit and reassignment workflows, claim level pricing validation, and rules driven payment integrity controls within the Optum Prospective Payment environment.
Operational scope targeted commercial inpatient claims, with primary impact on claims operations, payment integrity, coding audit teams, and provider reimbursement review processes at Blue Cross Blue Shield of Michigan. The engagement began as a targeted audit program to validate coding accuracy and reimbursement consistency, scoped to inpatient DRG populations.
Governance changes incorporated programmatic audit workflows, exception routing into claims adjudication queues, and documented review and case management processes to support coding validation and subsequent reimbursement actions. Rollout sequencing emphasized audit cadence and adjudication handoffs rather than systemwide claims platform conversion.
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Health Plan of San Joaquin | Healthcare | 480 | $85M | United States | Optum | Optum Prospective Payment | Insurance Claims Management | 2024 | n/a |
In 2024 Health Plan of San Joaquin implemented Optum Prospective Payment to support facility claim grouping, editing and pricing for its Medi-Cal business in California. The implementation went live March 25, 2024 and was focused on claims and pricing accuracy and regulatory compliance for Medicaid-managed care providers.
The Optum Prospective Payment deployment leveraged the EASYGroup and Rate Manager capabilities to operationalize prospective payment logic, rules-based claim grouping, automated edit checks, and facility-level pricing calculations. These modules were configured to enforce state Medicaid pricing rules and to support Insurance Claims Management workflows around adjudication, pricing validation, and payment integrity.
Operational coverage centered on the plan's Medi-Cal product in California, affecting claims operations, payment integrity, and compliance teams responsible for Medicaid-managed care provider adjudication. Governance was organized around centralized configuration of pricing rules and edits, with process changes to claims handling and approval workflows to reflect prospective payment enforcement.
Architecturally the implementation positioned Optum Prospective Payment as the facility claims pricing and grouping layer within the insurer's claims processing pipeline, with configurations tuned to California Medi-Cal rate and regulatory requirements. Rollout sequencing culminated in the March 25, 2024 go-live, aligning operational processes and controls with the new Insurance Claims Management capability.
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Insurance | 1000 | $900M | United States | Optum | Optum Prospective Payment | Insurance Claims Management | 2019 | n/a |
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