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Important note: Be advised that the following answers to frequently asked questions are general guidelines for 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 member materials or call Member Services for information on your specific health plan.

If you need answers to other questions, or need to ask about a specific plan and benefits please call Member Services from 8 a.m. to 5 p.m. Monday through Friday at the phone number listed on your ID card. If you are not a member and need information about enrolling, call 757-552-7401. TDD lines for the hearing impaired are 757-552-7120 or 1-800-225-7784.

Enrollment

What plans do you offer?

Optima Health offers many products for large and small group employers, such as HMO, PPO and Consumer Directed Health plans. These products include: Optima Vantage, Optima Plus, Optima Equity, Optima Design and Optima FourSight. Optima Health offers a Health Maintenance Organization (HMO) for Virginia Medicaid and FAMIS beneficiaries called Optima Family Care. It is best to check with your employer to see if a health plan by Optima Health is an option for you. Individual Plans are offered for people who do not have coverage through their employer.

Do you offer an individual product?

Yes. Whether you go to school, are self-employed or between jobs, are ready to retire, have a family or don’t have a health plan through work, Optima Health has medical coverage that meets your unique needs. Learn more about Individual Plans (note: the online application process is not available for mobile devices - if you would like to apply online, please visit www.optimahealth.com/individual via a PC).

When and where do I call if I have questions?

Refer to this section of the Web site for answers to commonly asked questions. If you still have questions, contact Member Servicescontact Member Services.

Member ID cards

I have not received my Member ID card but need to see my doctor. What should I do?

Contact Member Services. If your application has been processed they will be able to give you your unique Member ID number. This number allows a doctor to verify your eligibility and bill your services to the health plan. If your doctor requires you to present a card at the time of service, Member Services will fax a sample of your card to his/her office.

Why do I need to carry my Member ID card?

Your Member ID card identifies you as a covered member of Optima Health. In addition, it provides information such as copay amounts, applicable deductibles, your Member ID number, and important phone numbers and addresses.

I received a new Member ID card in the mail but I already have one. Should I throw the new one away?

No. Unless you ordered a new card online or through Member Services the only reason you will receive a new card is if important information on it has changed. Always show your ID card to your doctor when you receive a new one.

How do I request a Member ID Card?

Sign in and view MyOptima or call Member Services. Once ordered the card should arrive in seven (7) to ten (10) business days.

After Hours Nurse Advice Line

Do You Need After Hours Nurse Advice?
Call the number on the back of your Member ID card.
Remember, in an emergency always call 911 or go to the nearest emergency department.

What should I do if I get sick or hurt after business hours or during the weekend?

If you have an illness, injury, or condition that occurs during an evening or weekend, you should call your PCP or Plan doctor’s office or the After Hours Nurse Advice Line number located on your Member ID card.

What happens when I call the After Hours Nurse Advice Line?

A registered nurse will ask you to describe your medical situation in as much detail as possible.  Be sure to mention any other medical conditions that you have, such as diabetes or hypertension.

Depending on the situation, you may be advised about appropriate home treatments, or advised that a visit to your Plan doctor will take care of it. If necessary, the nurse may direct you to a Plan urgent care center or emergency department.

After Hours Nurse Advice Line nurses have training in emergency medicine, acute care, OB/GYN, and pediatric care. The staff are well-prepared to answer medical or behavioral health questions for members and their dependents. However, since they are unable to access medical records, they cannot diagnose or medically treat conditions, order labs, write prescriptions, order home health services, or initiate hospital admissions or discharges.

Emergency Care

What should I do if I have an emergency?

In any life-threatening emergency situation, always go to the closest emergency department or call 911.

If you received emergency care and are admitted, you or a family member should contact Optima Health within 48 hours (two business days) or as soon as medically possible. This enables Optima Health to arrange for appropriate follow-up care, if necessary. Also note that in each of these situations care may be reviewed retrospectively to make sure it met the criteria for coverage of emergency/urgent care treatment.

How can I tell if it is an emergency?

An emergency is the sudden onset of a medical condition with such severe symptoms or pain that an average person with an average knowledge of health and medicine (prudent layperson) would seek medical care immediately because there may be serious risk to your physical or mental health, or that of your unborn child.

Some examples of situations that would require the use of an emergency department include but are not limited to:

  • heart attack/severe chest pain
  • loss of pulse or breathing
  • stroke
  • poisoning
  • loss of consciousness
  • convulsions

What conditions generally do not require emergency department treatment?

The following conditions do not ordinarily require emergency department treatment, and may be more appropriately treated in your doctor’s office, or at a Plan urgent care center:

  • sprains or strains
  • chronic conditions such as arthritis, bursitis, or backaches
  • minor injuries and puncture wounds of skin

What is the difference between an emergency department and an urgent care center?

An emergency department is designed, staffed, and equipped to treat life-threatening conditions. An urgent care center is a more appropriate place to seek treatment for sudden acute illness and minor injuries when your doctor’s office is closed or not available. Copayments and coinsurance amounts for emergency department visits are generally higher than copayments for urgent care visits. If you are transferred to an emergency department from an urgent care center, you will be charged an emergency department copayment/coinsurance.

Do I need to contact Optima Health or my primary care physician before going to the emergency department/urgent care center?

No. However if you are unsure whether to visit an emergency department or urgent care center, you can call your primary care doctor's office or the After Hours Nurse Advice Line at the number on your ID card.

What if I become ill when I am outside of Optima Health’s service area?

Your Plan includes coverage for emergency services when you are outside the service area. If you have an unexpected illness or injury when outside of the service area you should call the After Hours Nurse Advice Line at the number on your ID card. In any life-threatening emergency situation always go to the closest emergency department or call 911.

Remember, Optima Health may review all emergency department care retrospectively – after the fact—to determine if a medical emergency did exist. If an emergency did not exist you may be responsible for payment for all services.

What if I need to be hospitalized?

If you received emergency care and are admitted, you or a family member should contact Optima Health within 48 hours (two business days) or as soon as medically possible. This enables Optima Health to immediately begin reviewing your care and to arrange for appropriate follow-up care. Remember all emergency care may be reviewed retrospectively to make sure it met the criteria for coverage of emergency/urgent care treatment.

If you are admitted to a hospital outside of Optima Health’s service area, call Member Services or the After Hours Nurse Advice Line at the number listed on your member ID card. Be prepared to give the following information:

  • Member name
  • Reason for treatment
  • Hospital name
  • City and state where treatment is occurring
  • Name of treating doctor

The doctor or hospital may also call Clinical Care Services.

What happens once I am admitted to the hospital?

As part of your Optima Health coverage, a case manager will follow your case from beginning to end. He or she will review your chart daily, check your progress, and arrange for your continuing care needs after you leave the hospital.

Mental Health Services

What about mental health services?

You may contact either Optima Behavioral Health at 757-552-7174 or 1-800-648-8420, or your primary care physician for guidance prior to seeing a mental health provider.

Is a referral for mental health inpatient services required?

No. If you need to be hospitalized, your mental health provider (not your primary care physician) will arrange for your admission to the appropriate in-network facility

Is there a way to handle emergencies for mental health?

Yes. Remember, in an emergency always call 911 or go to the nearest emergency department. For non-emergency behavioral health information after hours please call After Hours Nurse Advice Line at the number listed on the back of your member ID card.

Authorization for Use or Disclosure of Medical Information

How does Optima Health protect my personal information?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health plans protect the confidentiality of your private health information. Optima Health will not use or further disclose HIPAA protected health information (PHI) except as necessary for treatment, payment, and health plan operations, as permitted or required by law, or as authorized by you.

A complete description of your rights under HIPAA can be found in the Sentara Healthcare Integrated Notice of Privacy Practices. A copy of the notice will be included in your Evidence of Coverage (EOC) or Certificate of Insurance (COI) when you enroll. You can view a copy of our privacy notice online.

The Commonwealth of Virginia also has laws in place to protect the privacy of our members’ insurance information. We will not release data about you unless you have authorized it, or as permitted or required by law. Optima Health requires an Authorization of Designated Agent form whenever anyone other than the Optima Health member needs to obtain and/or change health information. You can download a copy of the form under Forms and Documents, or by calling Member Services at the number on your ID card.

Under HIPAA and Virginia law you have certain rights to see and copy health information about you. Under HIPAA you have the right to request an accounting of certain disclosures of the information and under certain circumstances, amend the information. You have the right to file a complaint with Optima Health or with the Secretary of the U.S. Department of Health and Human Services if you believe your rights under HIPAA have been violated.

Pharmacy

What is a tier?

Optima Health uses a prescription drug formulary. The formulary is a list of drugs that are covered under your Plan. Most Optima Health plans have a four (4) tier formulary. The tier your drug is placed in will determine your copayment or coinsurance amount. Drugs on Tier 1 will have the lowest out-of-pocket cost to you. Drugs on higher tiers will cost you more. To view an abbreviated version of this list or calculate drug costs, sign in and visit Pharmacy Resources.

How do I know what my copay is for a prescription medication?

Your copay tiers are listed in your Plan benefit documents. You must pay your applicable copay/coinsurance when you pick up your drug from the retail pharmacy. Some plans may also have a separate pharmacy deductible. If your Plan includes benefits for mail order prescription drugs you may be able to get certain maintenance drugs by mail for lower out-of pocket costs. To view an abbreviated version of this list or calculate drug costs, sign in and visit Pharmacy Resources.

Why do some drugs require pre-authorization?

Some drugs require pre-authorization by Optima Health in order to be covered. Your prescribing doctor is responsible for initiating pre-authorization. You should also check your Plan documents to see what medications may be excluded from coverage. You can view your plan documents by signing in and choosing “View Benefit Information” from the MyOptima menu. Optima Health may also establish monthly quantity limits for selected medications.

Can I order my maintenance prescription drugs through the mail?

Yes, if you have a pharmacy benefit and it is administered by Optima Health. Visit Mail Order Prescription for instructions.

Primary Care Physicians

What is a primary care physician (PCP), and why do I need one?

Your Plan primary care physician (PCP) is your point of contact to coordinate your healthcare needs. They can provide both the first contact for an undiagnosed health concern as well as continuing care of varied medical conditions. Depending on your PCP for routine medical care and guidance when seeking care within the Optima Health network can increase your satisfaction with the Plan and with your care. You will be asked to select an in-network or Plan PCP for yourself and each of your eligible dependents when you enroll.

How do I choose a PCP?

When you enroll in an Optima Health Plan, you will be asked to choose a PCP for yourself and each of your dependents. New members can often continue relationships with their present doctor or select a doctor with an office more convenient to their home or work addresses. You have the right to choose any PCP who participates in our network and who is available to accept you and/or your dependents. For children, you may choose a participating pediatrician as their PCP.

You can review a list of participating providers for your Plan online at optimahealth.com. You can choose or change your PCP online by signing in, selecting Change Primary Care Physician from the MyOptima menu, and following the onscreen instructions. In most cases, your PCP selection will be effective the next business day.

Please note, you do not need prior authorization from Optima Health or from any other person, including your PCP, to access obstetrical or gynecological or other specialty care from a healthcare professional in our network. The healthcare professional may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or other Plan requirements.

If you have not seen your designated PCP within the last 24 months, please contact your PCP’s office or Member Services to ensure that the office still lists you as a patient. Having your correct PCP on file ensures that any correspondence or other outreach to your PCP is accurate.

What about my spouse and children? Do we all have the same PCP?

You have the right to choose any PCP who participates in our network and who is available to accept you and/or your family members. You may select the same PCP for everyone, or each member can select their own PCP.

Generally, adults choose a family practice or internal medicine doctor for their PCP. For children, you may choose a participating pediatrician as their PCP.

What if my Plan doctor leaves the Optima Health network?

If your Plan doctor leaves the network, Optima Health will notify and assist you in finding a new doctor or facility. If you are in active treatment with a doctor who leaves the network you can request to continue receiving healthcare services from the doctor for at least 90 days. If you are beyond the first trimester of pregnancy you may be able to remain with that doctor through the provision of postpartum care directly related to the delivery. For a terminal illness, treatment may continue for the remainder of the member’s life for care directly related to the terminal illness.

Referrals

Referrals are not required for any Optima Health plans

What if I need to see a specialist?

You do not need a referral from your Primary Care Physician for specialist care. If you and your PCP decide you need to see a specialist, your PCP will coordinate your care and you can make your own appointment. Before you see a specialist, you should confirm that the specialist is in Optima Health's network. Visit Find a Doctor or contact Member Services at the number on your ID card to make sure that your specialist is in the network.

What if my doctor directs my care to a non-network doctor?

It is your responsibility to ensure that you are using in-network doctors and facilities. If you have an Optima Vantage plan and your doctor directs you to a non-network doctor, you will be responsible for payment of these services. If you have a POS plan, you have the option of using in-network doctors, or out-of-network doctors. Claims from out-of network doctors will be paid at a reduced benefit level and you will usually pay higher deductible, copay, and coinsurance amounts. You may also be balance-billed for any charges in excess of the Plan’s allowable charges. To find a in-network doctor, use the Find a Doctor or Find a Facility search feature or download a Provider Directory, or call Member Services at the number on your Member ID card.

Is my specialist authorized to order diagnostic or X-ray tests for me?

Yes, but some tests may require pre-authorization by the Plan.

Do I need a referral for my annual GYN exam?

No. Your plan does not require referrals. Female members may schedule an appointment for a routine annual exam with any OB/GYN in Optima Health’s network.

Can an OB serve as Primary Care Physician while I am pregnant?

Yes, during your pregnancy, your OB can serve as your PCP.  As a Plan member, you are automatically eligible for Optima Health’s Partners in Pregnancy program. This program is designed to provide education and support to pregnant women. If you would like more information about the program, simply call 1-866-239-0618, option 1.

Who is responsible for making sure the doctors I see and the services I receive are covered under my health plan?

It is your responsibility to ensure that you are using in-network or Plan doctors and facilities.

If you have an Optima Vantage plan and your Plan doctor directs you to a non-Plan provider, you
will be responsible for payment of these services.

If you have a POS plan, you have the option of using Plan providers, or non-Plan providers.  Claims from non-Plan providers will be paid at a reduced benefit level and you will usually pay higher deductible, Copayment, and coinsurance amounts.  You may also be balance billed for any charges in excess of the Plan’s allowable charges.  To find a Plan provider, use the Find a Doctor or Find a Facility search feature or download a Provider Directory, or call Member Services at the number on your Member ID card.

Point-of-Service Plan Specifics

What is Optima POS?

If your employer offers one of Optima Health's fully insured Vantage products you may have the option to enroll in a POS plan which permits you and your eligible dependents to receive the full range of covered items and services from out-of-network doctors. During your enrollment, ask your employer for information about the Patient Optional POS plan available to you. Please keep in mind that if you choose to enroll in a POS plan your premium, copayment, and/or coinsurance for covered services may be different from that for the Vantage plan.

What does it mean to use out-of-network coverage?

It means you can select any doctor or medical facility you want regardless of whether or not they are in our network, as long as the service is a covered benefit. However, when you use out-of-network coverage or do not have a referral, it is your responsibility to initiate the pre-authorization process with doctor and you will have additional out-of-pocket costs.

If I have Optima POS, can I choose whether to stay in or go out of the network?

For most covered services, absolutely. Just be aware that going out of network will be more costly than staying in network.

Are there differences in cost between in-network and out-of-network benefits?

Yes. In-network care will generally cost less and you won’t need to file for reimbursement. If you decide to use your out-of-network benefits, you will pay a larger portion of the costs, take responsibility for filing for reimbursement, and be responsible for ensuring that your doctor has obtained pre-authorization for certain medical services and procedures if the benefit is covered.

Do I have a deductible?

If your plan has a deductible and if you choose to use your out-of-network benefit, you will have an annual deductible, as well as coinsurance provisions in which you pay a percentage of the medical bill.

Do I have to file claim forms?

You do not have to file claim forms for care when you use your in-network benefits. However, you are responsible for filing for reimbursement when you use out-of-network benefits.

Optima Plus Plan Specifics

What is Optima Plus?

The Optima Plus, Optima FourSight, Optima Equity, and Optima Design plans feature in-network and out-of-network benefits. You make the choice of which coverage you want to use each time you seek care. When you use your coverage — either in-network or out-of-network — you should follow the procedures outlined in this guide. Remember, your out-of-pocket costs will be higher when you use out-of-network benefits. Below are characteristics unique to in-network and out-of-network coverage options.

What does it mean to be out-of-network?

Out-of-Network Coverage means

  • You have the freedom to go out-of-network and see any doctor you choose for covered services.
  • Generally, with out-of-network coverage, an annual deductible applies. You will also pay a percentage (coinsurance) of the medical bill.
  • With out-of-network coverage, your out-of-pocket costs, including out-of-pocket maximums, are generally higher.
  • If your plan has a deductible, you will need to meet your deductible before your coinsurance will apply.

Before you use your out-of-network benefits, follow these steps:

  • Get pre-authorization when necessary. You are responsible for ensuring that your doctor obtains pre-authorization before you receive care. Without pre-authorization, your coverage may be reduced or denied and a penalty will apply.
  • If you paid or received a bill for covered medical services, please submit an original copy of the bill and your Member ID number to:
          Medical  Claims
          P.O. Box 5028
          Troy, MI 48007-5028

Your claim will be processed in accordance with your out-of-network benefits.

* You will be responsible for paying all charges in excess of Optima Health’s allowable charge, in addition to any copay and coinsurance amounts you are required to pay. Charges from out-of network doctors will generally exceed Optima Health’s allowable charge.

If I have Optima Plus can I choose which option I want to use in-network or out-of-network on a case by case basis?

Absolutely. Just be aware that going out-of-network will be more costly than staying in network.

What's the benefit to me if I stay in-network and use a preferred provider?

In-Network coverage means:

  • In order to receive benefits at the in-network level, you must receive your care from in-network doctors, including, but not limited to, doctors, facilities, and laboratories. 
  • Generally, you pay a set copay and/or coinsurance for services.  Depending on your plan, you may have to meet a deductible before coinsurance will apply.
  • Your out-of-pocket costs or copays/coinsurance amounts are generally lower, and you do not need to file for reimbursement.
  • Payments applied to the in-network, out-of-pocket maximum only apply toward the in-network maximum.

Any exceptions are noted on the Summary of Benefits included with your plan documents. Your Summary of Benefits is available in the View Benefit Information link under the MyOptima menu.  You will need to be registered and sign in to view these documents. 

Do I have to meet a deductible?

For most of our plans there is usually no deductible with in-network coverage. However, when you use your out-of-network coverage, you will always have an annual deductible, as well as coinsurance provisions in which you pay a percentage of the medical bill. With out-of-network coverage, your benefits are generally lower and your out-of-pocket costs higher.

Do I have to file claim forms?

Not if you use your in-network benefits. However, you are responsible for filing for reimbursement when you go out of network for care.

Is there a lifetime maximum benefit?

Refer to your plan documents for specific plan details. Members who have registered on our Web site can view their benefits in MyOptima.

What is a pre-existing condition?

A pre-existing condition is any medical condition, other than pregnancy, for which medical advice, diagnosis, care, or treatment was recommended or received within a six-month period ending on the enrollment date.

If your plan has a pre-existing condition exclusion or waiting period, you will not be covered for those specific pre-existing conditions for a period of 12 months. You may receive credit to reduce or eliminate the pre-existing condition waiting period for any creditable coverage if you were continuously covered under another health plan with no more than a 63-day break in coverage. Please refer to the Notice of Pre-Existing Condition Exclusion included with your plan documents, if applicable.

What is certificate of creditable coverage?

A certificate of creditable coverage is intended to help you and your dependents in case you lose or change health plan coverage. Under a federal law known as HIPAA, you or your dependents may need evidence of coverage to reduce a pre-existing condition exclusion period under another plan, to help get special enrollment in another plan, or to get certain types of individual health coverage. When you change healthcare coverage, or if you or your dependents lose coverage under a health plan, the plan sponsor is usually required to provide written certification of how long you and your dependents were covered under that plan. You or your dependents can also request a certificate of creditable coverage if one is not automatically provided to you. When you enroll in an Optima Health plan we ask that you include a copy of certificates of creditable coverage for you and your dependents so that we may ensure you receive credit for your prior coverage against any pre-existing condition exclusion periods under your Optima Health plan. Please call Member Services if you have any questions about obtaining a certificate of creditable coverage.

Individual Coverage

Do you offer an individual policy for the self-employed or retired?

Yes. Optima Health offers individual plans for individuals who do not have coverage through their employer or have retired but are not Medicare-eligible. Learn more about Individual Plans (note: the online application process is not available for mobile devices - if you would like to apply online, please visit www.optimahealth.com/individual via a PC).

If you were previously covered by Optima Health and had a qualifying event, you may qualify for COBRA.

How do I get insurance coverage?

You can get a free quote or apply online, or you can call an Optima Personal Plan Advisor. Learn more about Individual Plans (note: the online application process is not available for mobile devices - if you would like to apply online, please visit www.optimahealth.com/individual via a PC).

I was covered through Optima Health and lost my job. Does that mean that I no longer have the option of insurance coverage?

No. If you were covered by Optima Health and had a qualifying event, you may be able to obtain and pay for coverage at the same benefit level through COBRA. You may also be eligible for an individual conversion plan. Contact your Benefits Administrator.

Web Site

I’m having trouble signing in. What can I do?

(Sign in features are not recommended for use on mobile devices)

Ensure you are following username and password requirements:

  • Usernames must begin with a letter and include only letters (a-z or A-Z), numbers (0-9) and underscore (_).
  • Usernames cannot include spaces or special characters and are not case sensitive.
  • Usernames can be a maximum of 20 characters long.
  • Passwords must be at least eight characters, include only letters (a-z or A-Z), numbers (0-9) and underscore (_).
  • Passwords cannot include spaces or special characters.
  • Passwordsare case sensitive.

How do I register?

If you are age 14 or older and a covered member of the health plan, simply go to the registration page. You will need to have your Member ID card available when registering.

Sentara employees do not need to register. Simply use your network or WaveNet sign in to access MyOptima.

(Not recommended for use on mobile devices)

Not yet registered? Register now

I have forgotten my Username and Password, what do I need to do?

If you have forgotten your password, visit Change Password. The secret answer you supplied during the registration process will allow you to reset your password. Keep in mind that the answer to your secret question is case sensitive. If you can’t remember the answer to your secret question, you will need to contact Member Services to have your password reset.

If you have forgotten your username you can complete the first step of the registration process again to recover your username.  If you have previously set up a username, your username will appear at the top of the registration page after you have submitted the registration form. You may also contact Member Services to find out your username.

Who should I contact for help?

FAQ - members

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