Complaints, Coverage Decisions and Appeals

As a member of an Optima Medicare plan, we want to work with you to resolve any problems or concerns you have about our health plan, your coverage for medical services or prescription drugs, your experiences at your doctor’s office, pharmacy, hospital, or other facility, and/or the quality of the care you receive.

Important information is included here to help you with issues you may experience. You cannot be disenrolled from an Optima Medicare plan or penalized in any way if you file a complaint, request a coverage decision or file an appeal.

More information about complaints, coverage decisions, and appeals can be found in your Evidence of Coverage (EOC). To view your EOC, please submit your ZIP code and navigate to your plan information.

In your EOC, Medicare uses different terms to describe complaints, coverage decisions, and appeals. These terms are explained below:

Grievance
A complaint.
Organization Determination
A coverage decision about a Part C medical service or item.
Coverage Determination
A coverage decision about a Part D prescription drug.
Reconsideration
First level appeal of an organization determination/coverage decision for a Part C medical service or item.
Redetermination
First level appeal of a coverage determination/coverage decision for a Part D prescription drug.

Appoint a Representative

You can have someone help you file a complaint, request a coverage decision, or file an appeal. If you do not have someone with durable power of attorney, is your court appointed guardian or health care proxy, you can appoint a representative such as a relative, friend, advocate, or attorney. To appoint a representative, complete the Medicare form below or write a letter with all of the same information that is in this form.

Send the form or letter and legal documents (power of attorney or for your court-appointed guardian or health care proxy) to us with the completed form for the correct process below (see sections on complaints, coverage decisions, and appeal).

The doctor that is treating you can file a complaint, request a coverage decision, or file an appeal on your behalf without having to be appointed as your representative.

File a Complaint

You can file a complaint with Optima Medicare or directly with Medicare. To learn more about filing a complaint, read about it in the Complaints, Coverage Decisions and Appeals Processes for Medicare Part C and D document.

Request a Coverage Decision

You can ask if we will cover or pay for Part C medical services or items or Part D prescription drugs. To learn more about requesting a coverage or payment decision, read about it in the Complaints, Coverage Decisions and Appeals Processes for Medicare Part C and D document.

File an Appeal about a Coverage Decision

You can file an appeal if we deny coverage or payment for Part C medical services or items or Part D prescription drugs. Follow the directions in the letter we sent to you that explains why we denied coverage or payment for services, items, or drugs. You can also read about it in the Complaints, Coverage Decisions and Appeals Processes for Medicare Part C and D document.


For information about the number of appeals, grievances, and exceptions filed with Optima Medicare, please use the contact information below:

Optima Medicare

Appeals Department
P.O. Box 62876
Virginia Beach, VA 23466-2876

Fax
(757) 687-6232
Fax (toll free)
+1 (866) 472-3920
Phone
+1 (800) 927-6048
TTY VA Relay Service
+1 (800) 828-1140 or 711