Appeals Process

If you have a problem or concern about Optima Health and/or the quality of care, services and/or policies and procedures of Optima Health, contact member services.

Optima Health has a formal process that allows for your concern to be addressed with the appropriate departments/persons within Optima Health. Research into your concerns are conducted in a timely manner to accommodate any clinical urgency of the situation. Upon research and completion, you will be notified of the resolution to your concern.

If your concern involves a denial of a covered service or claim, Optima Health includes a formal appeals process.

You may be eligible for a routine appeal, or an expedited appeal if an emergency medical condition exists. Download an appeal packet or contact member services at the number listed on your Member ID card to initiate the appeals procedure.

Steps to Take When Initiating an Appeal

To initiate the appeal process, submit your request in writing to:

You or your authorized representative have the right to submit written comments, documents records or any other information relevant to your case. If you have difficulty in obtaining this information, please contact the Appeals Department for assistance.

Relevant information includes:

• The Appeal Request Form describing the services or procedures requested and an explanation of why you feel Optima Health's decision was incorrect;
• Office notes from physicians that you have seen regarding the services or procedures in question;
• Medical records from hospitals and other health care providers;
• Physician correspondence;
• Physical, occupational, or rehabilitative therapy notes;
• Copies of bills you have received;
• Any additional information you would like Optima Health to consider in reviewing your appeal.

Upon Optima Health's receipt of your written request, you will have ten (10) days to submit any additional medical information. Any documentation received after the 10th day may not be considered in your appeal review.