CMS - External Infusion Pumps Policy

Changes in the Medicare Part B program will improve access to high quality, affordable biosimilars for people with Medicare as well as impose a $35 per month cost-sharing cap on insulin used in DME pumps.

Provider Manual Updates

An updated Optima Health Provider Manual will be released later this month.

PRSS - New Claims Platform

Optima Health launched its new claims platform on May 1, 2023, for Medicare claims only at this time. As part of this change, providers will have all EFT/ERA issued through PaySpan®.

New Clinical Policy Information

Optima Health has a new repository for clinical policies.

Exciting News

Optima Health Plan will assume agreements with Virginia Premier Providers on July 1.

New Medicare Claims Platform - An Update

Additional information to help you prepare for upcoming changes.

Authorization Required for Outpatient Services—Implementation Rescheduled for May 1

We previously announced that, effective April 1, 2023, we would no longer require an authorization for the first 15 visits for outpatient physical therapy (PT), occupational therapy (OT), and speech therapy (ST) for MAPD and DSNP members.

New Medicare Claims Platform Launches May 1

On February 1, we notified you of a change to the system we use to process Medicare claims. To ensure a smooth transition for all our providers, we have extended our implementation date from April 1, 2023, to May 1, 2023. Please see details below to learn more.

Ensure Your Online Provider Directory Information Is Accurate

Optima Health partners with LexisNexis. Unverified provider information cannot be included in our online directory.

Encourage Your Patients to Renew Their Medicaid Coverage

Starting in March 2023, Virginia will begin reviewing members’ health coverage to make sure they still qualify; however, members will not lose coverage prior to April 30, 2023.

Optima Health Will Temporarily Relax Authorization Requirements

Effective January 13, 2023, discharge to Optima Health in-network post-acute facilities will not require prior authorization.

New Vision Vendor Announcement

Optima Health is pleased to announce the selection of VSP®️ Vision Care to manage routine eye exams and materials benefits for commercial, Medicare, and Medicaid product lines, beginning January 1, 2023.

Sentara Healthcare Acquires AvMed, Inc.

Sentara Healthcare, one of the largest not-for-profit integrated health care delivery systems in the U.S. Mid-Atlantic region, has finalized the transaction with SantaFe HealthCare, Inc., for ownership of AvMed, Inc., a not-for-profit health plan in Florida.

Immediate Action Needed: Enroll in PRSS Today

As an Optima Health participating provider, you must take immediate action to initiate enrollment through the new PRSS (Provider Services Solution) enrollment wizard.

Temporary Action Needed by Medicare Providers to Avoid Claims Submission Denials

Optima Health discovered an error with Medicare ID cards distributed to members for 2023.

Optima Health to Implement New PBM

Effective January 1, 2023, Optima Health will change our pharmacy benefit manager (PBM) from OptumRx®️ to Express Scripts®️ for commercial, Medicare, and Medicaid plans.

Cardinal Care: Provider Agreement

As we prepare to transition to Cardinal Care in 2023, we recently announced amended provider information.

providerNEWS 4th Quarter 2022

Featuring: Virginia Medicaid Policy Updates – Cardinal Care, PRSS Enrollment Reminder, Help Close Care Gaps, Optima Medicare Advantage and Optima D-SNP Updates, New PBM, and More.

providerNEWS 3rd Quarter 2022

Featuring: COVID-19 Featuring: COVID-19 Coverage Extension Update, Jiva Update, Zelis Claims Review Implemented, Inova is Joining our Network, Dario Partnership Supports Members with Diabetes, Partners in Pregnancy Referral Program, Avalon Genetic Testing Implementation Delayed to 2023, Ensure Your Online Provider Directory Information is Updated, New Sleep Testing Services Program: Launch Date Postponed and more.