CareCentrix Post-Acute Care Services

Optima Health has contracted with CareCentrix to manage post-acute care services for our commercial members in Virginia, effective October 1, 2021 (previously scheduled to start on August 1).

New Online Provider Update Form

We are excited to announce the implementation of the new online Provider Update Form on our website! Network providers will now submit updated requests electronically, replacing the use of the PDF document/submission process by email for most requests. This is a more convenient and efficient process, which will result in faster processing by the health plan. Effective 9/6/21, paper/PDF provider update forms submitted by email will no longer be accepted.

Collaboration with Avalon Healthcare Solutions

Optima Health is proud to announce our new collaboration with Avalon Healthcare Solutions (Avalon) on a new laboratory benefit management program. Avalon will be providing Routine Testing Management (RTM) services to Optima Health. RTM, an automated review of high-volume, low-cost laboratory tests, provides consistent application of laboratory policies while remaining provider and member friendly.

Peer to Peer Provider Notification Changes

Effective 10/1/2021, Optima Health will implement the following changes to the provider peer to peer and reconsideration process.

Quarterly Provider Webinars August 2021

Join our network educators on August 4th at 10:00 a.m. or August 11th at 1:00 p.m. from the convenience of your office to learn what’s new at Optima Health, receive refreshers on how to successfully do business with us as well as have your questions answered.

providerNEWS 2nd Quarter 2021

Featuring: COVID-19 coverage extension update, post-acute care services for commercial members, Virginia regulatory changes for motor vehicle accident litigants and more.

DMAS Announces Enhanced Dental Benefits to Adult Members

After July 1, 2021, Optima Family Care will no longer offer enhanced dental benefits to Medicaid and FAMIS members. Beginning July 1, 2021, the Virginia Department of Medical Assistance Services (DMAS) will offer comprehensive dental services for 750,000 adult Medicaid and FAMIS members 21 and older.

Medical Necessity Criteria (MNC)

The Comprehensive Needs Assessment must document the need for crisis stabilization services. To qualify for this service, individuals must demonstrate a clinical necessity for the service arising from a condition due to an acute crisis of a psychiatric nature that puts the individual at risk of psychiatric hospitalization.

Crisis Stabilization Authorization Changes – Effective July 25, 2021: Comprehensive Needs Assessment (CNA)

The Comprehensive Needs Assessment is the initial face-to-face interaction encounter in which the provider obtains information from the individual, and parent, guardian, or other family members as appropriate about the individual’s mental health status and behaviors. The CNA serves to gather information to assess the needs, strengths, and preferences of the individual.

Behavioral Health Enhanced Services

Effective July 1, 2021, the Department of Medical Assistance Services (DMAS) will offer a new service, Assertive Community Treatment (ACT), to replace the current program, Intensive Community Treatment (ICT). ACT will include similar services currently offered through ICT, but now expands services to weekends and holidays.

Is Your Provider Directory Status Current?

It is important to routinely review and update your status on the Optima Health Online Provider Directory. This ensures members know your correct status, allowing them to make the best choices for their families. You may also confirm your status by calling provider relations.

Optima Health Announces Payment Policy Changes

Optima Health wants to make you aware of changes to our provider payment policies, effective August 1, 2021.

Quarterly Newsletter Supplement: Notification of Changes for Medicaid DME Services

Optima Health has received notice from the Virginia Department of Medical Assistance Services (DMAS) of its intention to implement a rate floor for durable medical equipment (DME), orthotics, prosthetics and supplies as a result of General Assembly action item #313 MMMM (“Action Item”).

New Behavioral Health Licensure Requirements

Effective July 1, 2021, the Department of Medical Assistance Services (DMAS) will offer a new service, Assertive Community Treatment (ACT), to replace the current program, Intensive Community Treatment (ICT).

Act Now: DBHDS Announces May 15 Deadline for Licensing Requirements

Optima Health wants to ensure you are aware of the licensure requirements recently announced by the Virginia Department of Behavioral Health and Developmental Services (DBHDS) and the Department of Medical Assistance Services (DMAS). Act now to meet the May 15, 2021 deadline related to Behavioral Health Enhancement (BHE) and the American Society of Addiction Medicine (ASAM) Levels of Care service modifications.

Low Acuity Non-Emergency ED Visits on the Rise

In recent months we have noticed an increase in the number of members with low acuity, non-emergent conditions visiting the emergency department.

providerNEWS 1st Quarter 2021

Featuring: COVID-19 coverage updates, information about our new provider information verification partner, education requirements for D-SNP providers, tips for addressing and preventing compassion fatigue and more.

Population Care Update for Providers: New Initiatives Support Member Health

Optima Health strives to have healthy members as part of our quality improvement initiatives. Learn more about three annual campaigns that support better health for your patients:

Communication and the Healthcare Experience

Did you know that communication is an increasingly important aspect of a patient’s healthcare experience?

New Balance Billing Protection

Beginning January 1, 2021, Virginia state law protects members from balance or “surprise billing.” Elective (self-funded) Group Health Plans must opt-in to this balance billing law at least 30 days prior to their effective date if they would like to offer this protection to their employees. Employers can choose to opt in effective January 1 or effective on the first day of the group’s plan year.