Coverage Decisions and Appeals

Provider Reconsideration Form
Download the form for requesting a claim review for members enrolled in an Optima Health plan.

Behavioral Health Provider Reconsideration Form
Download the form for requesting a behavioral health claim review for members enrolled in an Optima Health plan.

Medicare Advantage Waiver of Liability
Non–contracted providers who have had a Medicare claim denied for payment and want to appeal, must submit a signed Waiver of Liability Form to us. By signing this form, you agree to not bill the member for the services that have been denied.

Program Integrity Audit, Reconsideration, and Appeals Policy
Review the Optima Health Program Integrity Audit standards, including the process for reconsiderations and appeals of claims audit findings.