Hospital and Provider Selection Criteria for the Optima Health Network

Provider Selection

The provider networks for Optima Health plans, including those available on the Health Insurance Marketplace, consist of primary care, specialist, and behavioral health providers; and include physicians, physician assistants, nurse practitioners, and other qualified licensed clinicians.

Optima Health selects providers based on specific criteria and credentialing requirements to create a network that ensures members are able to access participating providers within a reasonable distance and time.

All providers must have completed a comprehensive credentialing application and be approved by the Optima Health Credentialing Committee before being accepted into the network. The credentialing process consists of the review, verification, and evaluation of a number of criteria; including (but not limited to) education, specialized training, board certification, hospital affiliations, state license(s), malpractice history, and sanction records. Providers with a felony conviction and/or sanction(s) by Federal government agencies are not accepted into the Optima Health Network. Providers are re-evaluated every three years.

The Optima Health credentialing process exceeds the requirements of the National Committee for Quality Assurance (NCQA) and the Commonwealth of Virginia quality measures for credentialing.

No member experience or cost-related measures are used in the provider selection process.

Hospital Selection

Hospitals for Optima Health plans, including those available on the Health Insurance Marketplace, are selected based on specific accreditation and accessibility criteria, ensuring members have access to quality hospitals within a reasonable distance and time.

Accreditation and licensure information is verified for all hospitals; an assessment is conducted to confirm the hospital is in good standing with state and federal regulatory bodies and that the hospital has been reviewed and approved by the appropriate national accrediting body.

To participate with Optima Health, hospitals must be accredited by the Joint Commission on Accreditation of Healthcare Organization (JCAHO), Healthcare Facilities Accreditation Program (HFAP), or DNV Healthcare Inc. Exceptions may be made for newly opening hospitals or hospitals in rural areas, which may be allowed to participate in the Optima Health network upon submitting documentation for patient safety plans and/or record of review from a state or federal regulatory body. Hospitals are re-evaluated every three years.

No member experience, patient safety, or cost-related measures are used in the hospital selection process.

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