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: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 yourplan materials or contact usfor information.
Eligibility
Claims
Referrals
Lab
Vision and Pharmacy
Plan Information
Eligibility
How can I verify my eligibility?
Use Provider Connection or call the Interactive Voice Response (IVR) at 757-552-7474 or 1-800-229-8822, option 2.Provider Connection 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.
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Claims
Can I submit my claims electronically?
Yes.Practices who file electronically benefit from documentation of claims transmission, faster reimbursement, reduced claims suspensions and lower administrative costs. There is no per claim charge to submit claims electronically.For more information see the EDI TransactionOverviewor contact Provider Relations.
What is the address for submitting paper medical claims to HOV?
P.O. Box 5028 Troy, MI 48007-5028
What are the timely filing deadlines for all claims?
All products have a 365-day, from date of service, timely filing deadline.
How can I check the status of my claim?
Use Provider Connection or call the Interactive Voice Response (IVR) at 757-552-7474 or 1-800-229-8822, option 2.Provider Connection 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.
What is the procedure for claim reconsideration requests?
Claim reconsideration requests should be sent directly to HOV attached to a Provider Reconsideration Form with block #19 of the HCFA 1500 claim form marked "Recon."
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Referrals
How can I check the status of my referral?
Visit Provider Connection or call the Interactive Voice Response (IVR) at 757-552-7474 or 1-800-229-8822, option 2.Provider Connection and the IVR are available 24 hours a day. The Provider Service Representatives can also assist Monday through Friday, from 8 a.m. to 4:30 p.m.
As an OB/GYN, can I refer members to another specialist?
- GYNECOLOGY: Not if the member has accessed your office through an open access policy.Members must first contact their PCP and have them referred to the specialist or have the PCP issue a referral to an OB/GYN provider and that OB/GYN provider may refer the member to another specialist using the specialist-to-specialist referral process.
- OBSTETRICS: While a woman is pregnant, the OB is considered the woman's PCP. As long as the OB has already obtained a global OB authorization from our Medical Care Management Department, he or she may refer the member for non-OB related specialist treatment.
How long is a specialist-to-specialist referral valid?
Specialist-to-specialist referrals are valid for the same length of time as the initial specialist referral from the PCP.
Can the second specialist see the member more than once?
Yes, the second specialist may see the member more than once if the referral does not include written limits on visits.However, that member cannot be referred to a third specialist without going back to his or her PCP.
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Lab
What reference labs do I send my lab work to?
Hampton Roads providers can send their lab work to Sentara, Maryview, Chesapeake General, Williamsburg Community, 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.Sending lab work to a non-participating lab may result in the member being billed or your office being denied for the services.
- Hampton Roads providers have the option of sending the patient with orders to a participating draw site. Please refer to the Network Directory for a list of draw sites.
- 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.
What lab work can I perform in my office?
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 theIn-Office Lab list.
What about pre-operative lab and X-ray?
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.
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Vision and Pharmacy
Who is the routine vision provider?
EyeMed Vision Care.
If my patient needs a routine eye exam and is a member of your health plan, how does he or she get information on their vision care benefits?
Members can find out all they need to know about their vision benefits by visiting Vision Benefits.
What is the mail order benefit?
Up to a 90-day supply for 2 copays for covered medications.
Who is the pharmacy mail order facility?
CareMark.
How would my patient utilize this benefit?
Members can download and print the mail order request forms. All you will need to do is write a 90-day prescription for the member on the appropriate form.
How do I know if a drug I prescribe is on the formulary?
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.
How do I get a drug pre-authorized?
You can contact Medical Care Management at 757-552-7540 or complete the appropriate drug pre-authorization form and fax to the health plan.
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Plan Information
How can I become a participating provider for Optima Health?
Providers interested in participating in the Optima Health provider network should contact Network Management at 757-552-8892.
What services are available to special needs members?
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.
What if my information is incorrect in the Provider Directory?
Contact Provider Relations.
What if I have a complaint?
Please contact Provider 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 Relations to initiate our provider reconsideration and appeal process.
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