Member Appeals and Grievances
Optima Family Care would like our members to be completely satisfied with the medical care and services they receive. Therefore, if you have a problem or complaint concerning the operation of the Plan, understanding of covered services, timeliness or quality of services provided, pre-authorization decisions or assignment of Primary Care Physicians (PCPs); a process has been developed for you to register your complaint so it can be resolved to your satisfaction. Should a problem or an incident cause you dissatisfaction, it is hoped that it can be resolved informally between you and the Plan staff or the provider involved. However, formal complaint procedures are available if your concerns cannot be resolved informally.
A member may file an appeal for reduced, terminated, or denied requests for service or denied claims (also called an adverse action). As an Optima Family Care member, you have the right to appeal directly to DMAS for a State Fair Hearing (SFH) before, during, after or instead of appealing to the Plan, despite the reason for reduced or denied medical services. Eligibility issues should be appealed directly to DMAS. To appeal to DMAS, the member should contact DMAS Appeals Department at 1-804-371-8488 or send a written request within 30 calendar days of receipt of a notice of adverse action/denial to:
Department of Medical Assistance Services
600 East Broad Street
Richmond, VA 23219
Additional information on the State Fair Hearing Appeal process, as well as SFH appeal request forms, are available