Complaints, Coverage Decisions, and Appeals
As a member of an Optima Medicare plan, we want to work with you to resolve any problems or concerns you have about our health plan, your coverage for medical services or prescription drugs, your experiences at your doctor’s office, pharmacy, hospital, or other facility, and/or the quality of the care you receive.
Important information is included here to help you with issues you may experience. You cannot be disenrolled from an Optima Medicare plan or penalized in any way if you file a complaint, request a coverage decision or file an appeal.
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Optima Medicare HMO Plans
The following information applies to Optima Medicare Value (HMO), Optima Medicare Prime (HMO), and Optima Medicare Classic (HMO) plans.
More information about complaints, coverage decisions, and appeals can be found in your Evidence of Coverage (EOC). To view your EOC, please submit your ZIP code and navigate to your plan information.
In your EOC, Medicare uses different terms to describe complaints, coverage decisions, and appeals. These terms are explained below:
- Grievance
- A complaint.
- Organization Determination
- A coverage decision about a Part C medical service or item.
- Coverage Determination
- A coverage decision about a Part D prescription drug.
- Reconsideration
- First level appeal of an organization determination/coverage decision for a Part C medical service or item.
- Redetermination
- First level appeal of a coverage determination/coverage decision for a Part D prescription drug.
Appoint a Representative
You can have someone help you file a complaint, request a coverage decision, or file an appeal. If you do not have someone with durable power of attorney, is your court appointed guardian or health care proxy, you can appoint a representative such as a relative, friend, advocate, or attorney. To appoint a representative, complete the Medicare form below or write a letter with all of the same information that is in this form.
Send the form or letter and legal documents (power of attorney or for your court-appointed guardian or health care proxy) to us with the completed form for the correct process below (see sections on complaints, coverage decisions, and appeal).
The doctor that is treating you can file a complaint, request a coverage decision, or file an appeal on your behalf without having to be appointed as your representative.
File a Complaint
You can file a complaint with Optima Medicare or directly with Medicare. To learn more about filing a complaint, read about it in the Complaints, Coverage Decisions and Appeals Processes for Medicare Part C and D document.
- File a complaint with Optima Medicare
- How to file a complaint with Medicare at Medicare.gov
- Form to use to file a complaint about Optima Medicare at Medicare.gov
Request a Coverage Decision
You can ask if we will cover or pay for Part C medical services or items or Part D prescription drugs. To learn more about requesting a coverage or payment decision, read about it in the Complaints, Coverage Decisions and Appeals Processes for Medicare Part C and D document.
- Request a standard decision for Medicare Part C (medical items or services)
- Request a standard decision for Medicare Part D (prescription drugs)
- Request a standard decision for Medicare Part D (prescription drugs) electronically
File an Appeal about a Coverage Decision
You can file an appeal if we deny coverage or payment for Part C medical services or items or Part D prescription drugs. Follow the directions in the letter we sent to you that explains why we denied coverage or payment for services, items, or drugs. You can also read about it in the Complaints, Coverage Decisions and Appeals Processes for Medicare Part C and D document.
For information about the number of appeals, grievances, and exceptions filed with Optima Medicare, please use the contact information below:
Optima Medicare
Appeals Department
P.O. Box 62876
Virginia Beach, VA 23466-2876- Fax
- (757) 687-6232
- Fax (toll free)
- +1 (866) 472-3920
- Phone
- +1 (800) 927-6048
- TTY VA Relay Service
- +1 (800) 828-1140 or 711
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Optima Community Complete (HMO D-SNP)
If you are a member of Optima Community Complete (HMO D-SNP) and you have a concern about your health plan, the quality of your care or your coverage for certain services, you may follow an established process to resolve your concern. You cannot be disenrolled from our plan or penalized in any way if you make a complaint, request a coverage decision, or file an appeal.
Official procedures for how to file a compliant, request a coverage decision, or file an appeal with Optima Medicare can be found below.
- Complaints, Coverage Decisions, and Appeals Procedures
- Request a standard decision for Medicare Part C (medical items or services)
Request a Coverage Decision
Request a standard decision for a prescription drug. The member, representative, or prescribing physician can submit this request. The request could be for a variety of reasons. Please review the forms for examples.
- Request a standard decision for Medicare Part C (medical items or services)
- Request a standard decision for Medicare Part D (prescription drugs)
Appeal a Coverage Decision
You can use these forms to request a reconsideration (appeal) of our decision if you disagree with Optima Medicare's decision to deny your request for coverage or payment for a Part C (medical item or service) or Part D (prescription drug) service. You can also file an appeal through Medicare.gov if you have exhausted your options through Optima Medicare.
- Request a Redetermination (appeal) for a Medicare Prescription Drug
- File a complaint with Optima Community Complete
- File an appeal for medical items or services
Appoint a Representative
Appoint a representative who can assist you in filing a complaint, requesting a coverage decision, or filing an appeal.
File a Complaint
Instructions for how to file a compliant with Optima Medicare. A complaint, or grievance, can be filed when you are not satisfied with the quality of care or services you received from your in-network provider or Optima Medicare. You can also file a complaint directly with Medicare.gov.
- Complaint Form from Medicare.gov
- Appeal Information from Medicare.gov
- Complaint information from Medicare.gov
Who to Contact
Information about the number of Appeals, Grievances & Exceptions filed with Optima Community Complete:
Optima Community Complete
Appeals Department
P.O. Box 62876
Virginia Beach, VA 23466-2876
Fax: 757-687-6232 or Toll-free Fax: 1-866-472-3920
TTY: VA Relay Service 1-800-828-1140 or 711