Appeals and Grievances

Appeals

You have the right to appeal any adverse benefit determination (decision) by Optima Health Community Care that you disagree with as it relates to coverage or payment of services. For example, you can appeal if Optima Health Community Care denies:

  • A request for a health care service, supply, item, or drug that you think you should be able to get, or
  • A request for payment of a health care service, supply, item, or drug that Optima Health Community Care denied.

You can also appeal if Optima Health Community Care stops providing or paying for all or a part of a service or drug you receive through CCC Plus that you think you still need. Send your Appeal request to: Optima Health Community Care Appeals, P.O. Box 62876, Virginia Beach, VA 23466-2876, toll-free phone number: 1-844-434-2916, and toll-free fax: 1-866-472-3920. If you submit your standard appeal by phone, it must be followed up in writing. Expedited process appeals submitted by phone do not require a written request.

If you disagree with our decision on your appeal request, you can appeal directly to DMAS. This process is known as a State Fair Hearing. You may also submit a request for a State Fair Hearing if we deny payment for covered services or if we do not respond to an appeal request within the times described in the Member Handbook. The State requires that you first exhaust (complete) the Optima Health Community Care appeals process before you can file an appeal request through the State Fair Hearing process. You may write a letter or complete a Virginia Medicaid Appeal Request Form. The form is available at your local Department of Social Services or on the DMAS website at dmas.virginia.gov/Content_pgs/appeal-home.aspx . You should also send DMAS a copy of the letter we sent to you in response to your appeal. You must sign the appeal request and send it to:

Appeals Division
Department of Medical Assistance Services
600 E. Broad Street
Richmond, Virginia 23219
Fax: 804-452-5454
Standard and Expedited Appeals may also be made by calling 804-371-8488.


Authorized Representative Form

You can give someone like your primary care provider, provider, friend, or family member written permission to help you with your State Fair Hearing request. This person is known as your authorized representative.

P202A Designated Representative Authorization Form.


Complaints

Optima Health Community Care will try its best to deal with your concerns as quickly as possible to your satisfaction. Depending on what type of concern you have, it will be handled as a complaint (also known as a grievance) or as an appeal. The complaint process is used for concerns related to quality of care, waiting times, and customer service. Here are examples of the kinds of problems handled by the Optima Health Community Care complaint process:

  • Complaints about quality
  • Complaints about customer service
  • Complaints about accessibility
  • Complaints about communication access
  • Complaints about waiting times
  • Complaints about cleanliness
  • Complaints about communications from us

Member Rights and Responsibilities

It is the policy of Optima Health Community Care to treat you with respect. We also care about keeping a high level of confidentiality with respect for your dignity and privacy. As a CCC Plus member, you have certain rights and responsibilities.

View your Rights & Responsibilities as a Member.