Complaints, Coverage Decisions, and Appeals
If you are a member of Optima Community Complete (HMO SNP) 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 our plan or penalized in any way if you make a complaint, request a coverage decision, or file an appeal.
Forms and Websites
- Appointing a Representative (PDF, 80KB)
Use this form to appoint a representative who can assist you in filing a complaint, requesting a coverage decision, or filing an appeal.
- Request a Coverage Determination for a Medicare Prescription Drug (PDF, 241KB)
Request a standard decision for a prescription drug. The member, representative, or prescribing physician can submit this request. The request could be for a variety of reasons. Please review the form for examples.
- Request a Redetermination (appeal) for a Medicare Prescription Drug (PDF, 296KB)
If you disagree with Optima Community Completes's decision to deny your request for coverage or payment for a prescription drug, you can use this form to request a reconsideration (appeal) of our decision.
- File a complaint with Optima Community Complete (PDF, 0.97MB)
The form and instructions for how to file a complaint with Optima Community Complete. A complaint, or grievance, can be filed when you are not satisfied with the quality of care or services you received from your in-network provider or Optima Community Complete.
- File an appeal for Optima Community Complete medical items or services (PDF, 0.98MB)
If you disagree with Optima Community Complete decision to deny coverage or payment for a medical item or service, please use this form and follow the instructions to request an appeal of our decision.
- Complaint information from Medicare.gov
Learn more about filing a complaint with Medicare.
- Complaint Form from Medicare.gov
The web-based form you can you use to file a complaint directly with Medicare.
- Appeal Information from Medicare.gov
Learn more about appeals and the different levels of appeals.
Who to Contact
Information about the number of Appeals, Grievances & Exceptions filed with Optima Community Complete:
Optima Community Complete
P.O. Box 62876
Virginia Beach, VA 23466-2876
Fax: 757-687-6232 or Toll-free Fax: 1-866-472-3920
TTY: VA Relay Service 1-800-828-1140 or 711