Provider Toolkit

Member ID Card Samples

• All Member ID Cards
• Commonwealth of Virginia

How To...

• Enter Orders for Tobacco Cessation in Epic Tip Sheet

• Manage Provide Connection Password
• Enroll in Self Service Password Reset by Setting Up Security Questions
• Navigate the Credentialing Process
• Navigate the AIM ProviderPortal
• Register for Provider Connection
• View and Create Pre-authorizations
• View Claims Status and Submit Reconsideration
• Avoid Common Claim Submission Errors
• View Remits Online
• Read an Optima Health Remit
• Understand Remittance Advice for Project Bravo Phases 1 & 2
• Locate Drug Formularies
• Locate Drug and Medical Prior Authorization
• Understand Critical Incident Reporting
• Create an Authorization
• Request EFT/ERA Setup or Change
• Respond to a Pre-payment Audit Notification from HMS

Respond to a Pre-Payment Audit Notification from HMS: Please follow the steps outlined in the letter you received from HMS. You could also use following links as a reference:

• Place of Service
• DRG Validation
• Inpatient Psych

Vendor Resources

Zelis

We partner with Zelis for claims editing services for Medicaid products. In response to inquiries about the adjustment codes, we have developed reference materials that includes sourcing and examples explaining why an edit is triggered. Zelis is considered a business associate of Optima Health, as defined by HIPAA. You may disclose protected health information (PHI) to Zelis without prior written participant authorization or consent. Zelis will perform periodic reviews of medical records to ascertain and/or verify charges billed to Optima Health.

Zelis will provide services including, but not limited to:

• ICD-l0 alignment with CPT/HCPCs coding accuracy
• clinical chart review
• laboratory coding
• coding and modifiers
• encourage follow-up visits via telehealth when appropriate to the principal diagnosis
• submit claims and encounter data timely

• Zelis Claims Cost Solutions - Edit Overview

CareCentrix

• CareCentrix

Forms

• Claims Project Request
• Critical Incident Report
• Doula Provider Recommendation Form - English Version
• Doula Provider Recommendation Form - Spanish Version
• Inogen Patient Referral
• Partners in Pregnancy Referral
• Provider Update Form
• Third Party Biller Denied Medical Claim Form (4+ Claims)

The Third-Party Biller Denied Claims Form was created to manage inquiries for four (4) or more denied claims. Traditionally, third party billing companies generate higher call volumes. This new process has been created with the goal of reducing call volumes and hold times as well as enhance the provider customer services team’s ability to provide more efficient problem resolution. Your first and best source of information is the Optima Health Remit. If after reviewing the remit you still have more questions you may submit an inquiry to Provider Customer Service. To initiate the inquiry you may download the form from the Provider Toolkit, then:

1. Fill out the form with the requested information regarding the four (4) or more denied claims
2. Print the completed form
3. Fax the form to the Provider Customer Service team at (757) 227-5110 or toll free (855) 939-7150.

Our agents will research the information and respond back to the third-party biller via fax within 72 hours. Please avoid duplicating requests through other avenues as it will cause delays. Important Note: The process for managing other call types will remain the same.