This page contains answers to frequently asked questions on a variety of topics. You may select a topic or question below, or simply scroll down to read all of the questions and answers.
Important note: Answers to common questions are general guidelines for most health plans offered by Optima Health. While most of the answers apply to all plans offered by Optima Health, there may be some slight differences. Please refer to your plan materials or contact us for information.
Use our secure online tools by signing in to Provider Connection
Provider Connection (not recommended for use on mobile devices) or call the Interactive Voice Response (IVR) at 757-552-7474 or 1-800-229-8822, option 2.
Our secure online Provider Connection Provider Connection (not
recommended for use on mobile devices) tools and the IVR are available 24 hours a day.
Provider Service Representatives can also assist Monday through Friday, from 8 a.m. to 4:30 p.m.
P.O. Box 5028 Troy, MI 48007-5028
All products have a 365-day, from date of service, timely filing.
Use Provider Connection Provider Connection (not
recommended for use on mobile devices) or call the Interactive Voice Response (IVR) at 757-552-7474 or 1-800-229-8822, option 2. Provider Connection Provider Connection (not
recommended for use on mobile devices) and the IVR are available 24 hours a day.Provider Service Representatives can also assist Monday through Friday, from 8 a.m. to 4:30 p.m.
Registered Providers may electronically submit reconsiderations online through Provider Connection by selecting “View Medical Claim Status”, entering the members Optima Health ID Number, selecting the claim in question and choosing the “Reconsider Claim” option. Providers are able to make changes or corrections on line for the following: CPT coding, diagnosis, billed charges, quantity and place of service.
Provider Reconsideration forms are also available under “Forms and Documents”. Reconsiderations submitted using the CMS 1500 form should indicate the original claim document number with the word “reconsideration” in field 19 of the form to prevent misidentification of the reconsideration as a duplicate claim.
No. Optima Health does not require referrals.
Providers have the option of sending the patient with orders to a participating draw site. A list of draw sites is available by selecting the “Find a Facility or Healthcare Service”.
- Hampton Roads providers can send their lab work to Sentara, Bon Secours Maryview, Chesapeake General, Sentara Williamsburg, and CHKD reference labs. EVMS is a specialty reference lab; call 757-446-5972 for the procedures they perform and to schedule a pick-up.
- Central Virginia and Statewide providers’ lab policies vary.Specific locations and the lab policies are outlined in the Provider Reference Manual.
Sending lab work to a non-participating lab may result in the member being billed or your office being denied for the services.
The In-Office Lab list includes a list of lab tests that the health plan will reimburse if performed in your office. In addition to this list, a limited number of additional lab tests may be performed in these specialists’ offices: dermatology, OB/GYN, oncology, infectious disease, reproductive medicine, rheumatology, and urology.
All PCP’s and specialists (except those located in North Carolina) are restricted to the In-Office Lab list.
Members having surgery at a participating hospital can be sent directly to the admitting hospital with a prescription for pre-operative testing.Pre-Operative lab can also be conducted through the Maryview, Sentara, CHKD, Chesapeake General Hospital, or Williamsburg Community Hospital reference labs (by courier pick up of the specimen or sending the member to a collection site).
Due to lab test processing and reporting time requirements, if surgery is scheduled with less than three (3) days notice, the lab test should be performed by the admitting hospital.
Vision and Pharmacy
Members can find out all they need to know about their vision benefits by visiting Vision Benefits.
Up to a 90-day supply for 2 copays for covered medications.
The formulary is referred to as the Preferred and Standard Drug List. You can review this list to identify what drugs are covered and which require pre-authorization.The Preferred and Standard Drug List is provided to all participating providers at the time of contracting, as updated and upon request.
Providers interested in participating in the Optima Health provider network should contact Network Management at 757-552-8892.
Members with physical, mental, language, and/or cultural barriers should be instructed to call Member Services at the number on the back of their ID card.
All auxiliary aids (e.g. TDD phone), sign language and foreign interpreter services will be made available to practitioners who provide services to our members.The TDD phone line is 757-552-7120 or 1-800-225-7784. A complete listing of resources for sign language/TDD services and language interpreters is included in an excerpt from the Provider Reference Manual.
Central Virginia and Statewide providers can see a complete listing of resources in an excerpt from the Statewide Provider Reference Manual.
Please contact Provider RelationsProvider Relations or your Network Educator to discuss the matter.We will make every effort to resolve the matter quickly and informally. If, however, you are not satisfied with the outcome, you may contact Provider RelationsProvider Connection (not recommended for use on mobile devices) to initiate our provider reconsideration and appeal process.