For questions about your complex condition, an upcoming procedure or for assistance with case management, you may contact our Clinical Care Services Team. Please identify yourself as a VCU Health System employee.
Optima Health Clinical Care Services Team
If you are new to Optima Health and are undergoing a course of care with an in-network provider, we recommend that you call your doctor’s or specialist’s office and tell them your coverage is changing to Optima Health. Your doctor can work with the Optima Health Clinical Care Services team to provide clinical notes and update any authorizations necessary.
If you are new to Optima Health and are undergoing a course of care with a provider who is not in the Optima Health network, then Optima Health will work with you to transition your course of care. Optima Health will review your case with you and your treating physician. Depending on your situation, you may be able to receive benefits at the in-network level for a period of time.
Certain healthcare services may require pre-authorization which is an evaluation process of the proposed treatment to determine medical necessity and whether the treatment is being provided is at the appropriate level of care. The provider is responsible for getting pre-authorization.
Generally, levels of care higher than traditional outpatient services require pre-authorization. The benefit summary provides full details on services requiring pre-authorization; the below list is not all-inclusive. Medical review is required for various services and treatments including (but not limited to):
- outpatient therapies and rehab services
- outpatient chemotherapy services and radiation services
- pre-authorized injectable and infused medications
- outpatient surgery services
- advanced imaging (e.g., MRI, MRA, PET, CT, CTA, MRS, SPECT, nuclear cardiology, sleep studies)
- outpatient services for maternity care
- inpatient services (including hospital services, transplants and skilled nursing facility services)
- non-emergency transportation (e.g., air, water, ground)
- diabetes treatment (e.g., insulin pumps, pump infusion sets and supplies)
- prosthetics (e.g., devices and components, repair, fitting, replacement, adjustment)
- Autism Spectrum Disorder
- durable medical equipment – for over $750 and for repair/replacement/rentals
- early intervention services (i.e., speech and language therapy, occupational/physical therapy, assistive technology services and devices from birth to age three)
- outpatient services for home health and hospice
- reconstructive breast surgery (i.e., surgery and reconstruction, prostheses, physical complications and lymphedema)
- clinical trials
- infertility services and injections
- hearing aids
- chiropractic care
- morbid obesity
Some drugs require prior authorization by Optima Health in order to be covered. Your prescribing provider is responsible for initiating prior authorization.
New Members: Optima Health will temporarily waive prior authorization requirements for members taking drugs that would usually require prior authorization. Your prescription must be filled within 60 days after your plan becomes effective (if filling at a retail location) or 120 days after the effective date (if filling through mail order). There are some exceptions to this and Optima Health representatives can help you with your transition. After this period, if you begin taking a new medication for which prior authorization applies then you will need to work with your doctor and pharmacist for approvals.