This section 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: Be advised that the following answers to common questions are general guidelines for 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 member materials or call Member Services for information on your specific health plan.
Enrollment
What plans do you offer?
Do you offer an individual product?
When and where do I call if I have a question?
Member ID cards
I have not received my Member ID card but need to see my physician. What should I do?
Why do I need to carry my Member ID card?
I received a new Member ID card in the mail but I already have one. Should I throw the new one away?
How do I request a Member ID Card?
After Hours Care
What if I get sick or hurt after business hours or on a weekend? Where do I go for medical care or advice?
What is the After Hours Nurse Triage Program?
How do I reach the After Hours Nurse Triage Program?
Emergency Care
How can I tell if it is an emergency?
What conditions are generally considered inappropriate for treatment in an emergency room?
Suppose it's an emergency?
Do I need a referral to go to an emergency room?
Am I covered if I’m injured and need dental care to save a tooth?
Out-of-Area Care
Suppose I'm out of town and need care?
Mental Health Services
What about mental health services?
Is a referral for mental health inpatient services required?
Is there a way to handle emergencies for mental health?
Release of Information
How can I be assured that my health information is kept private?
Pharmacy
My doctor told me that the drug he is prescribing is a Tier 1 drug. What is a tier?
How do I know what my copay is for a prescription medication?
Do I have a deductible?
Why do some drugs require pre-authorization?
Can I order my maintenance prescription drugs through the mail?
Primary Care Physicians
What is a primary care physician (PCP), and why do I need one?
How do I choose a PCP?
How can I change my PCP?
What about my spouse and children? Do we all have the same primary care physician?
Referrals
Suppose I need to see a specialist, what then?
Can I just go ahead and see a specialist now and get the referral later?
Is my specialist authorized to order diagnostic or X-ray tests for me?
Suppose my specialist says I need another specialist, do I need to go through my PCP first?
Do I need a referral to my OB/GYN for annual, routine exams?
What is the difference between a referral and pre-authorization?
Point-of-Service Plan Specifics
What is Optima Advantage POS?
What does it mean to use out-of-network coverage?
If I have Optima Advantage POS, can I choose whether to stay in or go out of the network?
Are there differences in cost between in-network and out-of-network benefits?
Do I have a deductible?
Do I have to file claim forms?
PPO Plan Specifics
What is Optima Premier PPO?
What does it mean to be out-of-network?
If I have Optima Premier PPO can I choose which option I want to use in-network or out-of-network on a case by case basis?
What's the benefit to me if I stay in-network and use a preferred provider?
Do I have to meet a deductible?
Do I have to file claim forms?
Is there a lifetime maximum benefit?
What is a pre-existing condition?
What is certificate of creditable coverage?
Individual Coverage
Do you offer an individual policy for the self-employed or retired?
How do I get insurance coverage if you do not offer it directly?
I was covered through Optima Health and lost my job. Does that mean that I no longer have the option of insurance coverage?
Web Site Issues
I’m having trouble signing in. What can I do?
How do I register?
I have forgotten my Username and Password, what do I need to do?
Who should I contact for help or technical problems?
If you need answers to other questions, or need to ask about a specific plan and benefits please call Member Services from 8 a.m. to 5 p.m. Monday through Friday at the phone number listed on your ID card. If you are not a member and need information about enrolling, call 757-552-7401. TDD lines for the hearing impaired are 757-552-7120 or 1-800-225-7784.
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Enrollment
What plans do you offer?
Optima Health offers many products for large and small group employers, including HMO, PPO, POS, patient-optional POS and Open Access POS plans. Optima Health also offers a Medicaid HMO, Optima Family Care, and a Medicare PPO, Optima Medicare Preferred. It is best to check with your employer to see if a health plan by Optima Health is an option for you. Individual and family plans are offered for people who do not have coverage through their employer. Visit our Health Plan Product Descriptions page for detailed information about our products.
Do you offer an individual product?
Yes. Whether you go to school, are self-employed or between jobs, are ready to retire, have a family or don’t have a health plan through work, Optima Health has medical coverage that meets your unique needs. Learn more about Individual and Family Plans.
When and where do I call if I have questions?
Refer to this section of the Web site for answers to commonly asked questions. If you still have questions, contact Member Services.
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Member ID cards
I have not received my Member ID card but need to see my physician. What should I do ?
Contact Member Services. If your application has been processed they will be able to give you your unique Member ID number. This number allows a provider to verify your eligibility and bill your services to the health plan. If your provider requires you to present a card at the time of service, Member Services will fax a sample of your card to his/her office.
Why do I need to carry my Member ID card?
Your Member ID card identifies you as a covered member of Optima Health. In addition, it provides information such as copay amounts, applicable deductibles, your Member ID number, and important phone numbers and addresses.
I received a new Member ID card in the mail but I already have one. Should I throw the new one away?
No. Unless you ordered a new card online or through Member Services, the only reason you will receive a new card is if important information on it has changed. Always show your ID card to your provider when you receive a new one.
How do I request a Member ID Card?
Visit My Optima or call Member Services. Once ordered the card should arrive in seven to 10 business days.
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After Hours Nurse Triage
What if I get sick or hurt after business hours or on a weekend? Where do I go for medical care or advice?
In an emergency, call 911 or go to the nearest emergency room. Otherwise, call your physician's office or our After Hours Nurse Triage Program at 757-552-7250 or 1-800-394-2237.
What is the After Hours Nurse Triage Program?
Calling After Hours puts you in touch with a professional nurse who can assess your medical situation, advise you where to seek care, and if possible, suggest self-care or address your problem until you can see your physician. After Hours nurses have training in emergency, acute, OB/GYN and pediatric care, and they're well prepared to answer your questions about members of all ages.
How do I reach the After Hours Nurse Triage Program?
Call 757-552-7250 or 1-800-394-2237 weekends, nights (5 p.m. to 8 a.m. Monday through Friday), and holidays.
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Emergency Care
How can I tell if it is an emergency?
An emergency medical situation is one that presents with a sudden onset of a medical condition with such severe symptoms, or pain, that an average person with an average knowledge of health and medicine would seek medical care immediately because there may be serious risk to your physical or mental health, or that of your unborn child.
Examples include but are not limited to:
· heart attack
· loss of pulse or breathing
· stroke
· poisoning
· loss of consciousness
· convulsions
· the sudden onset of a medical condition with symptoms so severe that the delay of immediate medical attention could jeopardize your mental or physical health, or that of your fetus
What conditions are generally considered inappropriate for treatment in an emergency room?
The following conditions do not ordinarily require emergency room treatment, but may be more appropriately treated in a physician's office:
· respiratory infections, sore throats, earaches, coughs
· sprains, strains, bruises
· insect bites (unless accompanied by breathing difficulties)
· fever of less than 12 hours duration (except for small children)
· chronic conditions such as arthritis, bursitis or backaches
· minor injuries and puncture wounds of skin (Tetanus booster shots are not required immediately after injury; they may be administered within five days)
· minor bladder and vaginal infections
Suppose it's an emergency?
In any life-threatening situation, you should always call 911 or go to the nearest emergency room.
Do I need a referral to go to an emergency room?
You do not need a referral to go to an emergency room. However, we review all emergency care retrospectively -after the fact- to determine if a true medical emergency did exist. If a true emergency does not exist, you may be responsible for payment.
Am I covered if I’m injured and need dental care to save a tooth?
If your health plan includes benefits for accidental dental benefit coverage, you are covered for services which are medically necessary as a result of accidental injury, and for which treatment is requested within 60 days of the accidental injury. All applicable copays, coinsurance and deductibles will apply. Please note that pre-authorization is required for stabilization and repair following the initial emergency treatment. Restorative services and supplies necessary to repair or replace sound natural teeth are excluded from coverage. Refer to your health plan documents for more information.
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Out-of-Area Care
Suppose I'm out of town and need care?
Non-Emergent:
If it is not an emergency, call your physician or the After Hours nurse for instructions on what to do. Remember, all outside-the-area care is reviewed retrospectively to make sure it was medically necessary and that coverage applies.
Emergency:
If it's an emergency, call 911 or proceed to the nearest Emergency Room. For ease in coordination of follow-up care, call Optima Health Member Services within 48 hours from the time care was rendered, or as soon as possible thereafter.
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Mental Health Services
What about mental health services?
You may contact either Sentara Behavioral Health Services at 757-552-7174 or 1-800-648-8420, or your PCP for guidance prior to seeing a mental health provider.
Is a referral for mental health inpatient services required?
No. If you need to be hospitalized, your mental health provider (not your primary care physician) will arrange for your admission to the appropriate in-plan facility.
Is there a way to handle emergencies for mental health?
Yes. Call 757-552-7174 or 1-800-648-8420.
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Release of Information
How can I be assured that my health information is kept private?
Please refer to our Notice of Privacy Practices for information on how we treat your personal information. We require a Release of Information/Authorization of Designated Agent form whenever anyone other than the member needs to obtain and/or change the member's health information. This form must be signed, witnessed and returned in order for it to be in effect.
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Pharmacy
What is a tier?
The drug tier placement determines the copay amount a member has to pay, with Preferred (Tier 1) drugs having the lowest copay. Optima Health uses a four-tier concept consisting of Preferred (Tier 1), Standard (Tier 2), Premium (Tier 3) and Premium Plus (Tier 4).
How do I know what my copay is for a prescription medication?
Registered optimahealth.com users can sign in to Pharmacy Resources to determine copay amount. You may also use our Drug Search, or ask your physician or pharmacist what tier the prescription drug is on. Then refer to the copay section of your Member ID card under Rx: for the applicable copay amount.
Do I have a deductible?
To determine if your health plan has a deductible for pharmacy, refer to your Member ID card. If your plan has a pharmacy deductible, the deductible amount will show under "Rx Ded:" under the copay section of the card.
Why do some drugs require pre-authorization?
To ensure you are receiving the appropriate medication for your condition based on review of medical criteria.
Can I order my maintenance prescription drugs through the mail?
Yes, if you have a pharmacy benefit and it is administered by Optima Health. Visit Mail Order Prescription for instructions.
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Primary Care Physicians
What is a primary care physician (PCP), and why do I need one?
For Health Maintenance Organizations (HMO) and Point-of-Service (POS) health plans, you will be required to select a PCP. Your PCP guides all of your healthcare and acts as your healthcare partner, making sure you get the care you need, when you need it.
How do I choose a PCP?
Use our Find a Doctor search feature or view our Provider Directory. If you were assigned to a PCP upon enrollment, you can change your PCP online through My Optima or call Member Services with your selection.
How can I change my PCP?
Sign in to My Optima or call Member Services at the number on your ID card. You can also visit the Find A Doctor search feature to find out the professional qualifications (i.e. medical school, board certification, etc.) of most plan physicians.
What about my spouse and children? Do we all have the same PCP?
That's up to you. Generally, adults choose either a family practice or an internal medicine physician, then a family practice physician or a pediatrician for their children.
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Referrals
Suppose I need to see a specialist, what then?
If your plan requires a referral for specialist care, your PCP will write a referral for you. When you receive a referral, it's a good idea to:
1) Confirm with the health plan that the referral is to a specialist in the plan's network;
2) Ask how many visits and the dates the referral covers; and
3) Check to see if the referral is for consultation or for consultation and treatment.
To ensure a referral has been processed, visit My Optima.
Can I just go ahead and see a specialist now and get the referral later?
No. Retroactive referrals are not covered. You will be financially responsible for any bills denied if your plan requires a referral and you have not obtained one prior to care being rendered. The only exception is for emergency services. Remember, too, that you are responsible for payment of any services not covered by your plan, so make sure you know your coverage. Plan specifics are outlined in your Summary of Benefits. To view your Summary of Benefits, visit My Optima.
Is my specialist authorized to order diagnostic or X-ray tests for me?
Certainly, as long as the tests are performed by a participating facility and, if your plan requires a referral for specialist care, your PCP has referred you to the specialist for consultation and treatment. If your plan requires a referral and your PCP refers you to a specialist for consultation only, testing will not be covered. In this case you must discuss the need for additional referrals with your PCP.
Suppose my specialist says I need another specialist, do I need to go through my PCP first?
No, as long as your specialist is referring you to another participating specialist for the same condition. If your specialist discovers another medical condition while treating you, you will need to go back to your PCP for another referral.
Do I need a referral to my OB/GYN for annual, routine exams?
No. If you are female and age 13 or older you do not need a referral to your plan participating OB/GYN for a routine annual exam.
What is the difference between a referral and pre-authorization?
A plan participating PCP will issue a referral to a participating specialist when a covered member needs specialist care. Pre-authorization is when the health plan’s medical care management department has given authorization to a provider that a procedure or treatment is listed as a covered benefit and is deemed medically necessary. Pre-authorization does not guarantee payment.
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Point-of-Service Plan Specifics
What is Optima Advantage POS?
Optima Advantage Point-of-Service (POS) is a health plan that allows you to use in-network benefits from participating providers (under the direction of your PCP) or out-of-network benefits from non-participating providers for care.
What does it mean to use out-of-network coverage?
It means you can select any physician or medical facility you want regardless of whether or not they are in our network, as long as the service is a covered benefit. Also, you can see physicians without referrals from your PCP. However, when you use out-of-network coverage or do not have a referral, it is your responsibility to initiate the pre-authorization process with your physician and you will have additional out-of-pocket costs.
If I have Optima Advantage POS, can I choose whether to stay in or go out of the network?
For most covered services, absolutely. Just be aware that going out of network will be more costly than staying in network.
Are there differences in cost between in-network and out-of-network benefits?
Yes. In-network care will generally cost less and you won’t need to file for reimbursement. If you decide to use your out-of-network benefits, you will pay a larger portion of the costs, take responsibility for filing for reimbursement, and be responsible for ensuring that your provider has obtained pre-authorization for certain medical services and procedures if the benefit is covered.
Do I have a deductible?
If your plan has a deductible and if you choose to use your out-of-network benefit, you will have an annual deductible, as well as coinsurance provisions in which you pay a percentage of the medical bill.
Do I have to file claim forms?
You do not have to file claim forms for care when you use your in-network benefits. However, you are responsible for filing for reimbursement when you use out-of-network benefits.
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PPO Plan Specifics
What is Optima Premier PPO?
Optima Premier PPO is a health plan featuring both in-network and out-of-network benefit options. This means members have the freedom to choose to receive healthcare in one of two ways:
1) from an in-network provider or
2) from any provider as long as the benefit is covered and you're willing to initiate the pre-authorization process.
What does it mean to be out-of-network?
It means you can select any physician or medical facility you want regardless of whether or not they are in-network, as long as the benefit is covered. However, when you use out-of-network coverage it is your responsibility to initiate the pre-authorization process and you will have additional out-of-pocket costs.
If I have Optima Premier PPO can I choose which option I want to use in-network or out-of-network on a case by case basis?
Absolutely. Just be aware that going out of network will be more costly than staying in network.
What's the benefit to me if I stay in-network and use a preferred provider?
By using a preferred provider- a physician or facility within the Optima Premier PPO network- you will pay lower out-of-pocket costs for the care you receive, plus you aren't bothered with filing for reimbursement.
Do I have to meet a deductible?
For most of our PPO plans there is usually no deductible with in-network coverage. However, when you use your out-of-network coverage, you will always have an annual deductible, as well as coinsurance provisions in which you pay a percentage of the medical bill. With out-of-network coverage, your benefits are generally lower and your out-of-pocket costs higher.
Do I have to file claim forms?
Not if you use your in-network benefits. However, you are responsible for filing for reimbursement when you go out of network for care.
Is there a lifetime maximum benefit?
Refer to your plan documents for specific plan details. Members who have registered on our Web site can view their benefits in My Optima.
What is a pre-existing condition?
A pre-existing condition is any medical condition, other than pregnancy, for which medical advice, diagnosis, care or treatment was recommended or received within a six-month period ending on the effective date of your policy. If your plan has a pre-existing exclusion or waiting period, you will not be covered for those specific pre-existing conditions for a period of 12 months. You may receive credit to reduce or eliminate the pre-existing exclusion waiting period for any creditable coverage if you were continuously covered under another health plan with no more than a 63-day break in coverage by submitting a certificate of creditable coverage as soon as you enroll.
What is certificate of creditable coverage?
If your plan has a pre-existing condition exclusion, you may be able to reduce or eliminate the pre-existing condition exclusion if you provide Optima Health with creditable coverage.
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Individual Coverage
Do you offer an individual policy for the self-employed or retired?
Yes. Beginning in 2008, Optima Health offers individual and family plans. Learn more about our individual and family plans. If you were previously covered by Optima Health and had a qualifying event, you may qualify for COBRA.
How do I get insurance coverage?
You can get a free quote or apply online.
I was covered through Optima Health and lost my job. Does that mean that I no longer have the option of insurance coverage?
No. If you were covered by Optima Health and had a qualifying event, you may be able to obtain and pay for coverage at the same benefit level through COBRA. You may also be eligible for an individual conversion plan. Contact your Benefits Administrator.
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Web site Issues
I’m having trouble signing in. What can I do?
Ensure you are following username and password requirements:
Usernames must begin with a letter and include only letters (a-z), numbers (0-9) and underscore (_). Usernames cannot include spaces or special characters and are not case sensitive.
Passwords must be at least six characters, include only letters (a-z), numbers (0-9) and underscore (_). Passwords cannot include spaces or special characters and are case sensitive.
How do I register?
If you are over 18 and a covered member of the health plan, simply go to the registration page. You will need to have your Member ID card available when registering.
Sentara employees with computer network access do not need to register. Simply use your network sign-in to access My Optima.
I have forgotten my Username and Password, what do I need to do?
If you have forgotten your username you will need to begin the registration process again. You may also contact Member Services to have your password reset.
If you have forgotten your password, visit Change Password. The secret answer you supplied during the registration process will allow you to reset your password. Keep in mind that the answer to your secret question is case sensitive. If you can’t remember your secret question and answer, you will need to re-register or contact Member Services to have your password reset.
Who should I contact for help or technical problems? Contact Member Services.
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