Frequently Asked Questions

This page contains answers to frequently asked questions on a variety of topics. You may select a topic or question below, or simply scroll down to read all of the questions and answers.

Important note: Answers to common questions are general guidelines for most health plans offered by Optima Health. While most of the answers apply to all plans offered by Optima Health, there may be some slight differences. Please refer to your plan materials or contact us for information.

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General Questions

  • Does Optima Health have online tools for providers?

    Yes, the Optima Health secure provider portal is called Provider Connection. Through Provider Connection, you can verify member eligibility and benefits, submit authorizations, and view claims and payment status. Provider Connection is available to contracted Optima Health providers and requires registration.

    Register for Provider Connection

  • Who can I contact if I have questions about claims, member benefits, eligibility, or plan participation?

    You can access eligibility, benefits and claims information through Provider Connection (available 24 hours a day) or by calling Provider Relations.

    If you need to confirm that you are a participating provider in your patient's Optima Health plan, you can use our directory to search for your provider profile. The "Plans Accepted" tab reflects the plans that you are currently contracted to accept as an in-network provider. You may also contact Provider Relations for this information.

    Medical Provider Relations: 1-800-229-8822

    Behavioral Health Provider Relations: 1-800-648-8420

    OHCC/LTSS Provider Relations: 1-844-512-3172


Provider Updates/Changes

  • What do I need to do if I am changing my practice information?

    Please notify Optima Health as soon as possible of any changes to practitioner or practice information. Provider updates can take up to 30 days to process, so please submit your request at least 30 days prior to the desired effective date of your change to avoid interruption/loss of reimbursement.

    You may submit your changes by using our Provider Update Form or contacting your Network Educator at 1-877-865-9075.

  • I am leaving one practice and joining another. Do I need to credential again?

    No, but you must notify Optima Health within at least 30 days of leaving your previous practice. If notification is more than 30 days from the time you have left your previous practice, it may be necessary for you to go through the credentialing process again.

    If you are moving to a solo practice or to a group who is not currently contracted with Optima, a new contract must be executed before you are able to rendering services under the new tax ID as an in-network provider.


Credentialing/Plan Participation

  • How can I become an Optima Health Provider?

    Providers interested in participating in the Optima Health network should download, complete, and submit the appropriate credentialing Application Packet*. Optima Health utilizes the CAQH (Council for Affordable Healthcare) application for our credentialing process. Please ensure completion of your CAQH application before submitting an application packet to Optima Health.

    Medical Providers: Medical Provider Application Packet

    Behavioral Health Providers: OBH Provider Application Packet

    Community Mental Health and Rehabilitative Services (CMHRS) Providers: CMHRS Application Packet

    LTSS Providers: Contact Centipede Health Network at 855-359-5391 or via email at joincentipede@heops.com.

    *Facility and Ancillary Providers: Please contact Network Management at 877-865-9075 to inquire about the contracting process.

  • How long does the credentialing/application process take?

    The credentialing process typically takes approximately 90 days from the time we receive a complete application.

  • Do I need to sign a contract?

    Yes. A completed contract is required before we can begin the credentialing process. If you are a new practitioner joining an already contracted group practice, no new contract will be necessary, and you will become party to your group's contract once your credentialing process is complete. You must be credentialed and contracted prior to rendering services to Optima Health members on an in-network basis.

  • How will I know when my application has been approved?

    You will receive an email from your Network Educator welcoming you to the network, advising you of your Optima Health effective date. Once you have received this notice, you may begin seeing members on an in-network basis.

  • How can I check the status of my application?

    If it has been more than 90 days since you submitted your complete application, and you have not been contacted by your Network Educator, you may contact Optima Health to inquire.

    Medical Providers: Contact Optima Health Credentialing at optima-credapps@sentara.com or 757-552-7193.

    Behavioral Health providers: Contact Optima Health Network Management at 1-877-865-9075, Option 3.

  • Can I begin seeing Optima members before I am credentialed (during the contracting/application process)?

    You must wait until you have received confirmation from Optima that you are a participating provider before providing services to Optima members on an in-network basis. Services provided prior to your Optima Health effective date may not be reimbursed. If your patient has out-of-network benefits, you may be able to provide services prior to becoming credentialed, however, this may result in a higher cost to your patient. Please always be sure to verify the member's benefits before providing services.


Claims

  • Can I submit my claims electronically?

    Yes. Electronic submission is the preferred method of claims submission. Providers who file electronically benefit from documentation of claims transmission, faster reimbursement, reduced claims suspensions and lower administrative costs. Providers can submit claims electronically through any clearinghouse that can connects through Allscripts/PayerPath.

    Optima Health Payer IDs:
    Medical: 54154
    Behavioral Health: 54154
    Institutional: 00453
    CMHRS: 5415M

    Optima Health can also accept electronic claims directly from providers who are able to submit an ANSI 837 file. For more information on submitting an ANSI 837, see the EDI Transaction Overview.

  • What is the address for submitting paper claims?

    Optima Medical Claims
    PO BOX 5028
    Troy, MI 48007-5028

    Optima Behavioral Health Claims
    PO BOX 1440
    Troy, MI 48099-1440

  • What are the timely filing limits for claim submission?

    365 days from the date of service. This includes any reconsiderations and appeals.

  • How can I check the status of my claims?

    You can view claims status and view your payment remits on Provider Connection or by calling Provider Relations.

    Medical Provider Relations: 1-800-229-8822

    Behavioral Health Provider Relations: 1-800-648-8420

    OHCC Provider Relations: 1-844-512-3172

  • How do I submit my claim for reconsideration?

    Reconsiderations/corrected claims submitted on a paper CMS 1500 form should include the word "Reconsideration" in field 19 to prevent misidentification of the reconsideration as a duplicate claim. Reconsiderations can also be submitted electronically. Please contact your clearinghouse to find out the specific requirements for submitting a reconsideration.

    Medical Providers may also submit reconsiderations online through Provider Connection by selecting "Medical Claims," selecting the claim in question, and choosing the "Reconsider Claim" option. Providers are able to make corrections online to CPT coding, diagnosis, billed charges, quantity and/or place of service.

  • Can I receive my reimbursements by EFT/direct deposit?

    Yes. Please complete and submit the Electronic Enrollment Form.

    Direct deposit is safe, secure, and efficient. Funds are typically deposited 24 hrs. after payments are processed. Once enrolled for EFT, you will no longer receive paper remits, and can access your remits through Provider Connection or from your clearinghouse. Please ensure you are registered for Provider Connection before enrolling in EFT — register for Provider Connection.

    If you are not a participating provider with Optima Health, you will need to obtain your remits through your clearinghouse or by calling Provider Relations.

    Medical Provider Relations: 1-800-229-8822

    Behavioral Health Provider Relations: 1-800-648-8420

    OHCC Provider Relations: 1-844-512-3172


Referrals

  • Does Optima Health require referrals?

    No.  Optima Health does not require referrals.

  • How can I increase the likelihood of receiving referrals?

    Most of our members access the online provider provider directory to locate a provider best suited to their needs (location, office hours, areas of focus, populations seen, etc.). Maintaining an accurate directory profile, including your availability, specialties, and areas of focus is the best way to ensure members have the opportunity to access your services.

    Please review your directory profile to ensure your information is accurate. If your provider directory profile is incorrect or needs to be updated, please contact your Network Educator as soon as possible and submit the correction to the Notification of Incorrect Provider Directory Information form.


Lab

  • What reference labs do I send my lab work to?

    Providers have the option of sending the patient with orders to a participating draw site. A list of draw sites is available by using the online provider directory. Members having surgery at a participating hospital can be sent directly to the admitting hospital with a prescription for pre-operative testing or a participating reference lab.

  • What lab work can I perform in my office?

    The In-Office Lab list includes a list of lab tests that the health plan will reimburse if performed in your office. In addition to this list, a limited number of additional lab tests may be performed in these specialists' offices: dermatology, OB/GYN, oncology, infectious disease, reproductive medicine, rheumatology, and urology. All PCP's and specialists (except those located in North Carolina) are restricted to the In-Office Lab list.


Pharmacy

  • How do I know if a drug I prescribe is on the formulary?

    You can review the formulary lists to identify what drugs are covered and which require pre-authorization on line. The Preferred or Standard Drug lists are provided to all Participating providers at the time of contracting, as updated, and upon request. You can also see the provider manual for more detailed information. For questions or more specific information about a member's formulary, please call Optima Pharmacy Member Services at 757-552-8877.

  • How do I get a drug pre-authorized?

    You may contact Optima Pharmacy Member Services at 757-552-8877 for assistance or complete the appropriate drug pre-authorization form and fax to the health plan.

  • What is the mail order Pharmacy benefit?

    Some members are eligible to receive up to a 90 day supply for medications taken on a regular basis, allowing members to receive their medications for 2 to 3 copays for up to a 90 day supply. The plan's mail order benefit has a minimum day supply of 63 and no more than a 90 day supply.

    Members can download and print pharmacy mail order request forms. Providers may write a 90-day prescription for the member on the appropriate form or e-prescribe prescriptions to 1-888-637-5191.

    For more information about a member's mail order pharmacy benefit, please call Optima Pharmacy Member Services at 757-552-8877.

  • Who is the pharmacy mail order provider?

    OptumRx.


Appeals/Complaints

  • What if I have a complaint?

    Please contact Provider Relations or your Network Educator to discuss the matter. We will make every effort to resolve the matter quickly and informally. If, however, you are not satisfied with the outcome, you may contact Provider Relations to initiate our provider appeal process.


Centipede/Non-Traditional Service Providers

  • I am a Centipede Provider. How can I get more information about my contract, credentialing, or plan participation?

    Please contact Centipede Health Network at 855-359-5391 or via email at joincentipede@heops.com

  • How can I get more information about eligibility, plan participation, or claims status?

    You can contact Optima Health Community Care Provider Relations at 1-844-512-3172.


Provider Orientation/Education

  • Can I request an in-service education for myself and/or my office staff?

    Yes. Every participating provider is assigned a dedicated Network Educator for education and one on one support while doing business with Optima Health. Your Network Educator can provide in-office provider orientation and education for all participating providers (both new and established). Please contact Network Management at 1-877-865-9075 to schedule an appointment with your Network Educator.