Optima Medicare (PPO)
Grievance, Coverage Determination and Appeals Process for PARTS C and D
If you are a member of Optima Medicare Plans, and you have a concern about your health plan, the quality of your care or your coverage for certain services, you may follow an established process to resolve your concern. You cannot be disenrolled from Optima Medicare plans or penalized in any way if you make a complaint.
Appeals and Grievance Procedures for Part C
2010 EOC for Optima Preferred Plan
2010 EOC for Optima Value Plan
Appeals and Grievance Procedures for Part D
2010 EOC for Optima Preferred Plus Plan
2010 EOC for Optima Value Plus Plan
Appeals and Grievance Forms
- www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf: Use this form for appointing a Representative
- www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/ModelCoverageDeterminationRequestForm.pdf – use this form for requesting a standard decision for Part D
- www.cms.hhs.gov/cmsforms/downloads/CMS20034AB.pdf - use this form to request a hearing with an Administrative Law Judge
- www.optimahealth.com/OptimaHealth/Members/Unsecured/Resources/Pages/AppealsProcess.htm - use for Complaint Forms and instructions
- www.cms.hhs.gov/MLNProducts/Downloads/Form_Exceptions_final.pdf - use the Part D Coverage Determination Request Form (for use by providers)
Who to Contact
About general information or information about the number of Appeals, Grievances & Exceptions filed with Optima Medicare?
Optima Medicare
Appeals Department
P.O. Box 62876
Virginia Beach, VA 23466-2876
Fax: 757-687-6232 or Toll-free Fax: 1-866-472-3920
Phone: 757-687-6404 or Toll-free Phone: 1-800-927-6048
TTY/TTD: 1-800-828-1120