How OptimaFit Health Insurance Works

Out-of-Network Coverage and Balance Billing

For OptimaFit® HMO plans, Optima Health will pay for covered services our members receive from our in-network plan providers. Members will usually have to pay their plan copayments or coinsurance when services are received. Members must also pay any deductible amounts out of pocket before we will begin paying for covered services. To find out if a provider is in our network, use our provider directory search.

What is Balance Billing?

Providers and facilities that do not directly contract with Your health plan are referred to as Out-of-Network Non-Plan Providers. Your health plan is generally not required to cover non-emergency care that you get from Out-of-Network Non-Plan Providers. Under Your health plan, You’re responsible for certain cost sharing amounts such as Copayments, Coinsurance and Deductibles for Covered Services. Balance billing occurs when an Out-of-Network Non-Plan Provider bills You for covered charges above Your cost sharing amounts that Your plan did not pay.

When You Cannot Be Balance Billed:

An Out-of-Network Non-Plan Provider cannot balance bill or attempt to collect costs from You that exceed Your Plan’s In-Network cost sharing requirements, such as Copayments, Coinsurance and Deductibles, for the following Covered Services:

  • Emergency Services provided by an Out-of-Network Non-Plan Provider (health care professional or Facility). Your final diagnosis will not determine whether services are Emergency Services.
  • Non-emergency Surgical or Ancillary Services provided by an Out-of-Network health care professional at an In-Network Hospital, ambulatory surgical center, or other Facility. This includes professional services, including surgery, anesthesiology, pathology, radiology, or hospitalist services and lab services.

Your In-Network cost sharing requirement will be based on what Optima Health usually pays an In-Network Provider. If You have a high Deductible or catastrophic health plan, Your Deductible will be based on any additional amounts Your Plan must pay to the Provider. Any amounts You are responsible for under this protection must count toward the maximum amount You must pay for In-Network services. If You pay an amount that exceeds this, the Provider must refund that amount with interest.

When You receive services, We will provide an Explanation of Benefits (EOB) that will show the out-of-pocket amount You are responsible for.

Your health plan contracts with certain health care professionals and facilities. These are called “In-Network” Providers. Insurers are required to advise You, via their websites or on request, which Providers and facilities are in their networks. Health care professionals and facilities must also tell You which provider networks the participate in either on their website or on request. Using In-Network Providers may help You avoid additional costs.

Balance Billing for Other Covered Services from Out-of-Network Non-Plan Providers

Except for the services listed above, or if We have approved Your Covered Service as an Authorized Out-of-Network Service, all other Covered Services You receive from Out-of-Network Non-Plan Providers are not be covered and you will be responsible for all charges. Amounts you pay out of pocket for non-covered services will not count toward any deductibles or maximum out of pocket amounts for your plan.

Submitting a Claim

Optima Health in-network plan providers will usually file claims for members after they receive services. Members may have to file a claim if a provider is unable to file, or if a member sees an out-of-network provider. We do not use claim forms, but members must send us complete written proof of loss.  Proof of loss means that we have all the information we need to make a decision to pay a claim. Members can provide proof of loss by sending us an itemized bill for the services received. An example would be a bill from a doctor’s office or hospital listing the cost of services or tests done. Please make sure the bill includes all of the following:

    • name and address of the provider, doctor, or hospital
    • name and member ID number of the member who received services
    • date of the services
    • diagnosis and type of services received
    • the charge for each type of service received

Send the itemized bill and any other information you have about your claim to:

MEDICAL CLAIMS
Lason Systems
P.O. Box 5028
Troy, MI 48007-5028

Members who need help filing a claim can also call member services at the number on the back of their member ID card. Claims must be received by Optima Health within 365 days of the date of the service. We will not be responsible for or pay a claim we receive from a non-plan provider more than 365 days from the date of service.

Grace Periods and Claims Pending Policies During the Grace Period

Members must pay all monthly premiums to Optima Health when they are due. If payments are late, Optima Health will provide notice to members with information on how to keep coverage in force by payment of all premiums owed by the end of the grace period defined below.

Grace Period for Members Not Receiving Advance Premium Tax Credits (APTCs)

Optima Health provides a grace period of 31 days for payment of monthly premiums except for the first binder premium payment. During the 31-day grace period, coverage will continue. However, if we don’t receive the entire premium amount that is due by the end of the grace period coverage will be canceled back to the last paid-through date of the grace period. Members may be responsible to Optima Health for the payment of the portion of the premium for the time coverage was in effect during the grace period.

Grace Period for Members Receiving Advance Premium Tax Credits (APTCs)

Optima Health provides a grace period of 90 days if a member is receiving APTCs and has previously paid at least one full month's premium during the benefit year. During the grace period, Optima Health will:

    • pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claim payment for services rendered to the enrollee in the second and third months of the grace period
    • notify Health and Human Services (HHS) of such non-payment
    • notify providers of the possibility for denied claims when an enrollee is in the second and third months of the grace period

If a member who receives APTCs reaches the end of the 90-day grace period without paying all outstanding premiums, we will notify the member that coverage will be canceled. The last day of coverage will be the last day of the first month of the 90-day grace period. Members will be responsible for payment of all charges for claims that were pended during the second and third months of the grace period.

Outstanding Premium Balance From Prior Coverage

Optima Health will require members who were terminated for non-payment of premium to pay the outstanding balance remaining from the previous coverage period before accepting a new enrollment.

Retroactive Denials

In some situations, Optima Health may deny a claim after a member has already received services from a provider. This may happen if coverage is canceled for non-payment or loss of eligibility under a health plan due to a change in circumstance. This may also happen if we do a retrospective review of a member's medical records after services have been received to determine if the services were medically necessary.

Optima Health may review all emergency care retrospectively to determine if a true medical emergency did exist. This retrospective review policy is designed to protect Optima Health members from the high costs associated with unnecessary use of emergency departments and urgent care centers. If members handle non-emergencies as if they are emergencies by seeking treatment at an emergency department or urgent care center when a visit to a doctor’s office would suffice, members could be responsible for paying a greater portion or all of the charges.

Members can help prevent retroactive denials by always paying premiums on time. Members must always notify the Exchange promptly of a change in circumstance that might affect coverage. Members should also make sure to review all of our requirements to have health care services pre-authorized before receiving them.

Enrollee Recoupment of Overpayments

Members should contact us at the number on their bill if they believe they have paid more than they should for their premium and are due a refund.

Medical Necessity, Prior Authorization Timeframes, and Enrollee Responsibilities

Some health plan services require pre-authorization before members receive them. In some cases, if members do not follow our requirements for pre-authorization we may not pay for services. In most cases, physicians or other providers will be responsible for getting pre-authorization. We have instructions and procedures in place for physicians to obtain pre-authorization.

Pre-Authorization is an evaluation process we use to assess the medical necessity and coverage of proposed treatment. It also checks to see that the treatment is being provided at the appropriate level of care. Pre-Authorizations are approved or denied based on current medical practice and guidelines and not on incentives or bonus structures. Pre-Authorization is certification by Optima Health of medical necessity and not a guarantee of payment by Optima Health. Payment by Optima Health for covered services is contingent on the member being eligible for covered services on the date the covered service is received by the member.

Generally, the following types of services require pre-authorization:

  • Inpatient services
  • Surgery
  • Durable Medical Equipment (DME)
  • Prenatal maternity services
  • Home health care
  • Skilled nursing facility care
  • Physical, occupational, and speech therapy
  • Cardiac, pulmonary, and vascular rehabilitation
  • Hospice services
  • Clinical trials
  • Transplant services
  • Certain drugs and medications
  • Chemotherapy
  • Radiation therapy

Pre-Service Claims Decisions

A pre-service claim means a claim for a benefit that requires pre-authorization before the member has the service done.

Optima Health makes decisions on pre-service claims within 15 days from receipt of the request for the service. We may extend this period for another 15 days if we determine we need more time because of matters beyond our control. If we extend the period we will notify the member/provider before the end of the initial 15-day period. If we make an extension because we do not have enough information to make a decision, we will notify the member/provider of the specific information missing and the timeframe within which the information must be provided. We will make a decision within two business days of receiving all the required medical information needed to process the claim.  We will send the member and physician written notice of our decision.

Expedited Decisions for Urgent Pre-Service Claims

We will consider a request for medical care or treatment to be an urgent request if using our normal pre-authorization standards would:

  • seriously jeopardize the member’s life or health
  • seriously jeopardize the ability of the member to regain maximum function
  • in the opinion of a physician with knowledge of the member's medical condition, subject the member to severe pain that cannot be adequately managed without the care or treatment

We will notify the member and the provider of our decision not later than 72 hours from receipt of the request for service. If we require additional information to make a decision, we will notify the member/provider within 24 hours of receipt of the request. We will include the specific information that is missing and the applicable timeframes within which to respond to us.

Drug Exceptions Timeframes and Enrollee Responsibilities

OptimaFit plans have a closed prescription drug formulary.  That means we have a certain list of prescription drugs that we cover. If a drug is not on our formulary, we will not pay for the drug. Please see the list of drugs included on the Optima Health formulary.

We have a process in place to allow a member, a designated representative, the prescribing physician, or other prescriber to ask us to approve coverage of a non-formulary drug in the following circumstances:

  • if the formulary drug is determined by us, after reasonable investigation and consultation with the prescribing physician, to be an inappropriate therapy for the medical condition of the member
  • when the member has been receiving the specific non-formulary prescription drug for at least six months previous to the development or revision of the formulary and the prescribing physician has determined that the formulary drug is an inappropriate therapy for the specific patient or that changing drug therapy presents a significant health risk to the specific patient

An exception request for coverage of non-formulary drugs can be made by the member, a designated representative, the prescribing physician, or other prescriber. Requests can be made in writing, electronically, and telephonically.  To request a non-formulary drug, have a doctor or send a medical necessity form to our pharmacy authorization department at 4456 Corporation Lane, Suite 210, Virginia Beach, VA 23462, or call us at 757-552-7540 (toll-free 1-800-229-5522).

Standard Exception Requests for Coverage of Non-Formulary Drugs

We will make a decision on a standard exception request and notify the member, representative, or physician no later than one business day following receipt of the request. If the request is approved, coverage of the non-formulary drug will be provided for the duration of the prescription including refills and without additional cost sharing beyond that provided for formulary prescription drugs in the member's covered benefits.

Expedited Exception Request Based on Exigent Circumstances

Exigent circumstances exist when a member is suffering from a health condition that may seriously jeopardize the member’s life, health, or ability to regain maximum function; or when a member is undergoing a current course of treatment using a non-formulary drug. We will make a decision on an expedited exception request and notify the member, representative, or physician no later than 24 hours following receipt of the request. If the request is approved, coverage of the non-formulary drug will be provided for the duration of the exigency and without additional cost sharing beyond that provided for formulary prescription drugs in the member's covered benefits.

To request expedited review for exigent circumstances, send a medical necessity form to our pharmacy authorization department at 4456 Corporation Lane, Suite 210, Virginia Beach, VA 23462, or call us at 757-552-7540 (toll-free 1-800-229-5522).

External Exception Request Review

If we deny a standard or expedited request, we have a process in place to allow the request to be reviewed by an independent review organization. Notification of a decision on an external exception request will be given to the member, representative, or physician no later than 72 hours following receipt of the request if the original request was a standard request. If the original request was an expedited request, notification will be given no later than 24 hours following receipt of the request. If an external exception request is approved, we will provide coverage for the non-formulary drug for the duration of the prescription and without additional cost sharing beyond that provided for formulary prescription drugs in the member's covered benefits. For expedited exception requests, coverage of the non-formulary drug will be provided for the duration of the exigency and without additional cost sharing beyond that provided for formulary prescription drugs in the member's covered benefits.

To request an independent external review of our decision, you or your authorized representative should submit the request in writing at the address below or by calling us at 757-552-7540 (toll-free 1-800-229-5522). You may provide any documentation pertinent to your case or other information relevant to your request addressed to Medical Review Institute of America at 4456 Corporation Lane, Suite 210, Virginia Beach, VA 23462.

Please be advised that if you choose to have an authorized representative submit information on your behalf, you must submit a Designation Authorization Form signed by you along with the request. If a signed designation form does not accompany the request, the external review request will not be processed.

Information on Explanations of Benefits (EOBs)

After a member receives a health care service, Optima Health will send an Explanation of Benefits (EOB) notice to the member. The EOB will show what type of health care service the member received and how much the doctor or hospital has charged for the services.  The EOB will also show how much the health plan paid for the service and how much the member must pay out of pocket. 

Coordination of Benefits (COB)

Coordination of benefits happens when a member is covered by more than one health plan. Benefits can be coordinated so that the same services don’t get paid for twice. 

Members must tell Optima Health if they, or a covered family member, have coverage under any other health plan.  When a member has double coverage one plan normally pays its benefits in full as the primary payor. The other plan coordinates benefits and pays as the secondary payor. When we are the primary payor, we will pay the benefits described in your coverage document. When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

Special Enrollment Period (SEP)


Did you change jobs? Get married? These and other life events may qualify you to enroll in health coverage outside of the Open Enrollment Period. Talk to one of our OptimaFit Personal Plan Advisors at 1-800-741-4825

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