If you are dissatisfied with the care or service your received from one of our physicians or hospitals, or if you are dissatisfied with any of the services, policies or procedures of Optima Health you may file an informal complaint or a formal written complaint.
Informal Complaints
An informal complaint may be appropriate if you want to make us aware of a problem or a concern with care you received from one of our providers but you don’t necessarily want the information shared with your provider, or you do not want your name used. Please follow these steps to file an informal complaint:
- Call Member Services at 1-800-927-6048 or (TTY) 1-800-828-1120 and let us know about your concern. You should call as soon as possible within 180 days of the date of the occurrence.
- The Member Services representative may ask you for additional information so that we may research the issue. We won’t contact your provider and you don’t have to give us your name. The information that you provide us about your complaint will be used for training and education purposes only.
- We may follow up your phone call with a letter written to you stating that we received and processed your grievance as an informal complaint.
Formal Written Complaints
You may choose to file a formal written complaint. Formal complaints are thoroughly investigated by contacting all involved parties, including the provider of your service and obtaining all information regarding the issues. We then prepare a formal written response based on our investigation. A formal complaint should be made in writing as soon as possible within 180 days of the occurrence. Please follow these steps to file a formal written complaint:
- Formal complaints should always be in writing. Contact Member Services for a copy of instructions and complaint forms. Tell Member Services if you need help with writing your complaint, or if for some reason you are unable to file a written complaint.
- Once you complete the written complaint form it should be mailed to:
Optima Medicare
Post Office Box 62876
Virginia Beach, VA 23466-2876.
You may also fax your written complaint form to Optima Health at 757-687-6232.
What is a coverage determination?
Whenever you ask for a Part D prescription drug benefit, the first step is called “requesting a coverage determination.” When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request.
You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.
Who may ask for a coverage determination?
You can ask us for a coverage determination yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us at Optima Medicare, 4417 Corporation Lane, Virginia Beach, VA 23462, attn: Member Services. Download an Appointment of Representative form.
What is an appeal?
An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug.
Who may file your appeal of the coverage determination?
The rules about who may file an appeal are almost the same as the rules about who may ask for a coverage determination. For a standard request, you or your appointed representative may file the request. A fast appeal may be filed by you, your appointed representative, or your prescribing physician.
How to request a coverage determination or appeal
You, your doctor, or your appointed representative should call us at 1-800-927-6048 (for TTY, call 1-800-828-1120). These numbers may also be used for process or status questions. Or, you can deliver a written request to Optima Medicare, Attn: Pharmacy Authorizations, 4417 Corporation Lane, Virginia Beach, VA 23462, or fax it to 757-552-7516 or 1-800-750-9692. Our Medicare Drug Authorization Forms may be used to request a coverage determination or appeal.
Who may file your appeal of the coverage determination?
The rules about who may file an appeal are almost the same as the rules about who may ask for a coverage determination. For a standard request, you or your appointed representative may file the request. A fast appeal may be filed by you, your appointed representative, or your prescribing physician.
Evidence of Coverage
Section 12 of the Evidence of Coverage (EOC) discusses the grievance, coverage determination, and appeals processes.