Complaints, Coverage Decisions and Appeals Processes

Medicare Parts C and D

If you are a member of Optima Medicare HMO Plans, 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 Optima Medicare plans or penalized in any way if you make a complaint, request a coverage determination or file an appeal.

Official procedures for how to file a compliant, request a coverage decision, or file an appeal with Optima Medicare can be found below.

More information about complaints, coverage decisions, and appeals can be found in the Evidence of Coverage - in order to view the correct documents for your area, please submit your zip to proceed.

Request a Coverage Decision

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 forms for examples.

Appeal a Coverage Decision

You can use these forms to request a reconsideration (appeal) of our decision if you disagree with Optima Medicare HMO's decision to deny your request for coverage or payment for a Part C (medical item or service) or Part D (prescription drug) service. You can also file an appeal through Medicare.gov if you have exhausted your options through Optima Medicare.

Appoint a Representative

Appoint a representative who can assist you in filing a complaint, requesting a coverage decision, or filing an appeal.

File a Complaint

Instructions for how to file a compliant with Optima Medicare. 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 Medicare. You can also file a complaint directly with Medicare.gov.

Who to Contact

Information about the number of Appeals, Grievances & Exceptions filed with Optima Medicare:

Optima Medicare 
Appeals Department
P.O. Box 62876
Virginia Beach, VA 23466-2876
Fax: 757-687-6232 or Toll-free Fax: 1-866-472-3920
Phone: 1-800-927-6048
TTY VA Relay Service 1-800-828-1140 or 711