optum

What optum does

Optum Workers' Comp and Auto No-Fault is a division of Optum, Inc., a wholly-owned subsidiary of UnitedHealth Group, providing pharmacy benefit management, clinical oversight, PPO network access, medical bill review, and ancillary services for the workers' compensation and auto no-fault insurance markets. The division serves insurance carriers, third-party administrators, self-insured employers, state workers' compensation agencies, and injured workers across the United States, currently serving over 500,000 injured persons with a reported 92% average satisfaction rate. Core technology assets include the Tmesys workers' compensation-specific pharmacy network of nearly 60,000 retail, home delivery, and specialty pharmacies; the Procura non-risk PPO network; the VitalPoint provider and claims portal; TruCase case management; MicroStrategy-based reporting; One Healthcare ID single sign-on; and a patent-pending clinical data analytics model plus a patent-pending urine drug testing program developed under the Chief Clinical Officer. State-certified Managed Care Organization, Medical Care Plan, Managed Health Care Plan, Preferred Provider Plan, and Medical Provider Network credentials are maintained in California, Connecticut, Georgia, Kentucky, Illinois, New Jersey, New York, and West Virginia.

Revenue is generated through transaction-fee pharmacy benefit management, subscription/recurring PPO and state-certified MCO services, and transactional ancillary and medical bill review services delivered under multi-year enterprise contracts with carriers and TPAs. Distribution is primarily direct enterprise field sales led by a Chief Business Officer, supplemented by self-service digital portals (VitalPoint, ProviderHub, TruCase) and channel relationships through affiliate partners Anthem, Networks by Design, and MagnaCare. Operations are HIPAA-compliant and URAC Gold accredited across multiple legacy entities (PMSI, Progressive Medical, Cypress Care, Healthcare Solutions, Procura Management) that now operate under the Optum brand.

Name

optum

Legal name

Optum, Inc.

Website

https://workcompauto.optum.com

Company type

Private

Founded year

1974

Operating status

Operating

Headcount range

251–500 employees

Short description

Optum Workers' Comp and Auto No-Fault is a UnitedHealth Group division providing pharmacy benefit management, clinical oversight, PPO networks, and ancillary services for workers' compensation and auto no-fault claims, serving 500,000+ injured persons through a 60,000-pharmacy network and state-certified managed care operations.

Ownership category

akta.pro rank

Product category

Workers' Compensation and Auto No-Fault Pharmacy Benefit Management

NAICS

Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292)

akta.pro primary industry

Pharmacy Benefit Management (PBM) & Pharmacy Network Administration (HLAFALAI)

akta.pro secondary industries

Workers’ Compensation PPO Networks (HLAEANAH), Auto/No-Fault PPO Networks (HLAEANAI)

Keywords

• Pharmacy benefit management
• Workers compensation services
• Auto no-fault claims
• Medical bill review
• PPO network management

Headquarters

HQ city

Eden Prairie

HQ country

United States

HQ region

North America

Offices2 records

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Operations, Technology or R&D, Marketing or Sales, Supply Chain

Revenue model

1. Pharmacy Benefit Management: Pharmacy benefit management services for workers' compensation and auto no-fault claims including pharmacy bill review, drug formulary management, and prescription processing through Tmesys network.
2. PPO Network Services: Preferred Provider Organization network services providing access to contracted healthcare providers for workers' compensation and auto no-fault claims.
3. Ancillary Services: Ancillary services including clinical services, home delivery pharmacy, and medical supplies for injured workers and auto no-fault claimants.
4. Medical Bill Review: Medical bill review services to ensure proper coding, pricing, and compliance with workers' compensation fee schedules.
5. State Certified Managed Care Organization Services: Certified MCO/MCP/WCPPP services in states including California, Connecticut, Georgia, Kentucky, Illinois, New Jersey, New York, and West Virginia for workers' compensation medical management.

Pricing tiers

Go-to-market motion1 record

Distribution channels4 records

Marketing channels6 records

Core offering

Optum Workers' Comp and Auto No-Fault provides pharmacy benefit management, PPO network services, medical bill review, clinical oversight, and ancillary services for workers' compensation and auto no-fault claims. The division adjudicates prescriptions through the Tmesys network of nearly 60,000 pharmacies, delivers clinical programs supported by patent-pending analytics, manages a non-risk PPO network via Procura, and holds certified managed care organization status in multiple states.

Product overview

Optum Workers' Comp and Auto No-Fault is a comprehensive pharmacy benefit management platform offering workers' compensation and auto no-fault solutions. The core offerings include Workers' Compensation Pharmacy Services and Auto No-Fault Pharmacy Services, supported by proprietary portals (VitalPoint) and networks (Tmesys Pharmacy Network with nearly 60,000 pharmacies, Procura Network PPO). Additional modules include Medical Bill Review, Clinical Services with patent-pending data analytics, Ancillary Services, PPO Network Services, State Certified Networks across multiple states, Referral Forms, Ask-a-Pharmacist consultation, One Healthcare ID single sign-on, Digital Pharmacy Card, Topicals Toolbox, Policy Matters insights, Policy Talk Podcast, and Continuing Education programs. The platform operates URAC Gold accredited and HIPAA compliant.

Differentiator

Problem solved

Functional benefit

Brands

• VitalPoint: Provider treatment portal for pharmacy and claims management
• Procura Network
• Optum Workers' Comp and Auto No-Fault

Products and services

• Workers' Compensation Pharmacy Services Pharmacy benefit management solutions for workers' compensation claims, including medication management, formulary control, and utilization review to achieve optimal outcomes for injured workers. Delivered to insurance carriers, third-party administrators, and self-insured employers under enterprise contractual arrangements.
• Auto No-Fault Pharmacy Services Pharmacy benefit management solutions extending benefits for auto no-fault policyholders, delivering better experiences for claims professionals while managing medication costs. Delivered via the Tmesys pharmacy network and supported by clinical oversight programs.
• VitalPoint Primary pharmacy and claims management portal offering pharmacy locator, treatment tracking, claims reporting, and 24/7 access to pharmacy services, claims management, and clinical services for clients and providers.
• Tmesys Pharmacy Network National workers' compensation-specific pharmacy network comprising nearly 60,000 retail pharmacies, home delivery, and specialty pharmacies for claims processing and adjudication. Operates as an affiliate of Optum Rx and enables nationwide online claims submission, approval, and processing.
• Procura Network Non-risk PPO network offering injured persons easy access to quality healthcare providers nationwide for both workers' compensation and auto no-fault claims, with provider lookup tools and panel cards.
• Medical Bill Review Medical bill review services to ensure proper coding, pricing, and compliance with state fee schedules for workers' compensation and auto no-fault claims.
• Ancillary Services Ancillary services including physical therapy, durable medical equipment, home delivery pharmacy, medical supplies, and other supporting treatments for injured workers and auto no-fault claimants.
• Clinical Services Clinical oversight programs, utilization review, and pharmacist support services, including a patent-pending data analytics model and patent-pending urine drug testing program for monitoring medication therapy and identifying potential misuse.
• PPO Network Services Preferred provider organization network services providing access to network providers for medical care management in workers' compensation and auto no-fault claims.
• State Certified Networks (MCO/MCP/WCPPP/MHCP) State-certified managed care organization services in California (MPN via Anthem and Networks by Design), Connecticut (MCP), Georgia (WC/MCO), Kentucky (MHCP), Illinois (WCPPP), New Jersey (MCO), New York (Certified PPO via MagnaCare), and West Virginia (MHCP), providing utilization review, case management, and medical director oversight.
• Ask-a-Pharmacist Clinical pharmacist consultation service for questions about dosage, medication therapy, or specific medications related to workers' compensation or auto no-fault claims.
• Digital Pharmacy Card Digital pharmacy benefit card accessible via mobile wallet (Apple Wallet, Google Wallet) or PDF download, used by injured workers at pharmacies in the Tmesys network.

Quantifiable outcome

• 92% average satisfaction rate
• +2 more outcomes

Named customers4 records

Segments5 records

Ideal customer profiles4 records

Technology focussed Yes

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Integration3 records

Feature5 records

Partnerships

Five partnerships are on record, tiered core and minor.

• AnthemcoreStrategic or Co-development PartnerAffiliate partner providing Medical Provider Network (MPN) services in California in alignment with Administrative Rules §9767.1-19. Anthem provides access to a comprehensive network of providers specializing in workers' compensation treatment.
• Networks by DesigncoreStrategic or Co-development PartnerAffiliate partner providing Medical Provider Network (MPN) services in California for workers' compensation MPN programs including case management, utilization review, and medical bill review.
• MagnaCarecoreStrategic or Co-development PartnerAffiliate partner providing Certified Preferred Provider Organization (Certified PPO) services in New York through opt-in arrangement with state workers' compensation board, covering Albany, Bronx, Dutchess, Erie, Kings, Monroe, Nassau, New York, Niagara, Oneida, Onondaga, Orange, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Suffolk, and Westchester counties.
• Optum RxcoreStrategic or Co-development PartnerParent organization affiliate relationship where Tmesys, a national workers' compensation-specific pharmacy network, operates as an affiliate of Optum Rx providing pharmacy benefit management services, home delivery, and specialty pharmacy.
• CEU InstituteminorOthersThird-party organization administering continuing education credits for Optum's CE webinar programs for adjusters, case managers, nurses, and rehabilitation counselors.

Scale indicators6 records

Recent moves6 records

Expansion highlights6 records

Broad incumbents

• Express Scripts (Evernorth / Cigna): Largest US PBM with growing presence in workers' compensation pharmacy services. Broader PBM portfolio enables cross-sell and scale advantages, and competes with Optum's pharmacy network and formulary management capabilities.
• Coventry Workers' Comp Services (CVS Health/Aetna): Workers' compensation managed care division of Aetna, owned by CVS Health. Competes directly in WC PPO networks, utilization review, and case management, with broader CVS/Caremark PBM scale as a competitive advantage.

Direct peers

• Healthesystems: Specialized workers' compensation pharmacy benefit manager and ancillary services provider. Direct competitor in WC PBM with overlapping customer base of carriers, TPAs, and self-insured employers, and similar focus on clinical oversight programs.
• CorVel Corporation: National managed care company providing workers' compensation claims management, PPO networks, and bill review services. Closest public-market comparable with analogous integrated WC managed care offering.
• myMatrixx (by Enlyte): Workers' compensation pharmacy benefit management and clinical services company owned by Enlyte (formerly Mitchell). Directly competes in WC PBM, bill review, and claims management with comparable product breadth.
• One Call Care Management (One Call): Workers' compensation specialty services network providing ancillary services, physical therapy, diagnostics, and pharmacy network access. Overlaps significantly in ancillary and network services to the same carrier and TPA customers.
• Mitchell International (Enlyte): Provider of workers' compensation auto casualty claims management, pharmacy benefit management, and bill review solutions. Parent of myMatrixx; competes with Optum's TruCase, VitalPoint, and medical bill review offerings.
• Aspen Claims Management: Workers' compensation managed care organization providing utilization review, case management, and bill review services in multiple states. Competes directly with Optum's certified MCO services in overlapping state markets.
• Concentra (Select Medical): Occupational health services provider with workers' comp clinical services, employer clinics, and ancillary services. Competes in overlapping ancillary services and network access offerings within WC.

Emerging players

• Helios (Workers' Comp Focus): Workers' compensation technology and services company providing pharmacy network access and claims workflow tools. Overlaps with Optum's network access and digital pharmacy card offerings in the WC ecosystem.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat6 records

Key risks6 records

Key highlights7 records

Customer concentration

• LinkedInlinkedin.com/company/workcompauto.optum

Compliance11 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles14 records

Subsidiaries6 records

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about optum