Transitioning Virginia Premier Providers
Welcome to Optima Health
Effective July 1, 2023, Optima Health Plan will assume the existing Virginia Premier agreements with Virginia Premier Providers. As of the merger effective date, Optima Health will assume all of Virginia Premier’s rights and obligations under the agreement.
Optima Health Plan, a Virginia non-profit corporation, shares the same values as Virginia Premier and merging with them will help solidify our efforts to ensure that we continue to offer exceptional care and service to our consumers, members, patients and communities. It also helps us to better anticipate and respond to changes in our industry and to identify opportunities for growth and innovation.
Starting July 1, 2023, Virginia Premier Medicaid will become a part of Optima Health.
- The Virginia Premier Medicaid product will now be branded Optima Health and the Virginia Premier name will no longer be in use for Medicaid. Medicaid member ID cards will use Optima Health, Group Number: VP.
- This change means that DMAS will remove Virginia Premier from their Medicaid documents, enrollment broker/Maximus, websites, health plan comparison charts, etc.
- As the CMS contracted DSNP program will end December 31, 2023, Virginia Premier D-SNP, Virginia Premier Advantage Elite, will remain a product of Virginia Premier.
Summary of business operations beginning on July 1
- Group Number VP is an important distinction enabling Optima Health to administer the provider agreements for benefits and claims payments.
- Submit all Group Number VP claims to Payer ID VAPRM
- Generally, conducting business with Optima Health Group Number VP will remain the same as you have experienced historically with Virginia Premier. You will receive timely notice of any process changes in the future.
Provider Orientation Opportunities
We are hosting Virginia Premier/Optima Health Merger: Provider Orientation sessions one per week during the months of June and July.
Contracts
Combining Optima Health and Optima Health Group Number VP
At this time, contracts shall remain separate for the two product lines: Optima Health Medicaid and Optima Health, Group Number: VP. We foresee combining contracts but will ensure that both DMAS and Optima Health are able to administer the change efficiently and accurately for our provider partners. We will ensure timely notice.
Important: Optima Health, Group Number: VP identifies legacy Virginia Premier provider agreements for claims adjudication.
Corporate Address
(For general health plan correspondence and deliveries. Not intended for claims submission or appeals. See Conducting Business Beginning July 1 for that information.)
U.S. Mail
Sentara Health Plan
PO Box 66189
Virginia Beach, VA 23466
Overnight Mail
Sentara Health Plans, Inc.
1300 Sentara Park
Virginia Beach, VA 23464
Remaining Informed
- The VPHP Newsletter is retired, effective immediately. You will begin receiving Optima Health providerNEWs by email. Additionally, current, and past editions of providerNEWs are available online.
- Optima Health Provider Alerts will replace Virginia Premier Provider Alerts Effective July 1
- Virginia Premier email addresses will continue to be forwarded to their intended recipients
Public Website Access
As there are processes central to your ability to manage Legacy Virginia Premier business as you do today, the website will remain active and continue to be branded as Virginia Premier, until further notice.
For relevant details on all Optima Health programs, please visit the website.
Seeing Patients July 1 – December 31, 2023
| Provider Scenario | |||
|---|---|---|---|
| Member Scenario | Legacy VPHP Provider Never OHP Contract Accepted |
Legacy VPHP Provider Never OHP Contract Declined |
OHP Provider Never VP |
| Optima Health: Group VP |
YES | NO | NO |
| Optima Health | YES | NO | YES |
| Optima Health: Group VP Newborn |
YES | NO | NO |
| Virginia Premier: DSNP |
YES | YES | NO |
| Kaiser Permanente | Requires contract w/Kaiser Permanente | Requires contract w/Kaiser Permanente | Requires contract w/Kaiser Permanente |
| Payer IDs | |||
|---|---|---|---|
| Group Number VP (Including newborns) VAPRM All Claims |
Virginia Premier (DSNP) VAPRM All Claims |
Optima Health 54154 – Professional/Medical 5415M – Professional/Behavioral Health 00453 – Institutional |
Kaiser Contact Kaiser directly for Payer ID |
Identifying Members
Group Number VP Card Sample
- Optima Health Group Number VP members will receive their new ID cards in June.
- If a member presents with a legacy Virginia Premier ID card membership eligibility should be verified to confirm they are under Group Number VP.
- Group Number VP is an important distinction enabling Optima Health to administer the provider agreements for benefits and claims payments.
Optima Health Card Sample
Kaiser Permanente Card Sample
The health plan formerly known as Virginia Premier had a relationship with Kaiser Permanente that will continue beyond July 1, 2023, expanding to Optima Health members in Northern Virginia. Kaiser Permanente member IDs will be uniquely distinguished with their company logo.
FAMIS
MEDICAID
Continuity of Care
Newborns: Legacy Virginia Premier newborns will be assigned to Optima Health Group Number VP.
Loss of Eligibility: Members who lose eligibility with Legacy Virginia Premier will be assigned to Group Number VP if re-enrolled within the renewal grace period.
Medicare/DSNP
Virginia Premier D-SNP, Virginia Premier Advantage Elite, will remain the same. DSNP is contracted with CMS and remains effective through December 31, 2023.
Key Contacts
The provider and member customer service numbers have been consolidated.
Provider/Member Customer Service: (800) 881-2166
- Select the health plan you are inquiring about:
- #3 Optima Health, formerly Virginia Premier (Group Number VP), then follow prompts to reach department
- #4 Optima Health, then follow prompts to reach department
Until further notice some departments can still be reached through the numbers you’ve dialed historically.
Group Number VP
- Transportation: (855) 880-3480
- Pharmacist Help Desk (including pre-authorization): (877) 779-2890
- Care Coordination: (800) 727-7536
- Provider Service Representative: Request support via email contactmyrep@virginiapremier.com
Optima Health
- Transportation: (877) 892-3986
- Pharmacist Help Desk: (844) 604-9165
- Care Coordination: (866) 546-7924
- Network Educator: (product and service updates, escalations) (877) 865-9075, Option #2
- Additional phone numbers
Portal Access
Group Number VP
You will continue to be able to access the Virginia Premier provider portal as you do today. The portal will be rebranded to Optima Health. Kaiser information will remain accessible.
- https://www.virginiapremier.com/providers/medicaid/provider-portals/
- The provider portal will remain available to verify eligibility, submit claims and claim reconsiderations and review claims and claim reconsideration history.
- The welcome page will be rebranded as Optima Health for Group Number VP (formerly the Virginia Premier Medicaid Plans).
Optima Health
Your Jiva experience through Optima Health will be slightly different in appearance and workflow. Explore Jiva resources.
Registration for Provider Connection, the Optima Health secure online provider portal, is required.
Conducting Business Beginning July 1
Group Number VP
Clinical Guidelines: The clinical guidelines for Group Number VP will not change to align to Optima Health at this time. While we are integrating, we are reviewing these policies to ensure we are taking the best steps for members and providers. During this period providers will continue to operate under the prior standards of each plan unless otherwise notified.
Viewing Eligibility: Members with Group Number VP will be distinguished as Optima Health (formerly Virginia Premier) on the DMAS portal.
Claims Submission:
- Electronic Claims Submission: We accept claims through any clearing house that can connect through Availity and Change Healthcare.
- Mail Paper Claims to: PO Box 5550, Richmond VA, 23220
Timely Filing: Please refer to your contract for your Practices Timely Filing Requirements. You have 365 days from the date of service to submit any corrections, reconsiderations, and/or appeals.
Turnaround time for clean (correctly submitted) claims:
- Auto Adjudication 6 days
- Manual Adjudication 19 days
Appeals – May be submitted in writing within 365 days from the date of service for claims appeals. Clinical appeals must be submitted within 60 days of notice of denial. Detailed information and supporting written documentation should accompany the appeal. A decision will be rendered within 30 business days of receipt of the appeal request, with a 14-day extension if it is in the best interest of the member.
Mail to:
Optima Health Appeals and Grievances
PO Box 6253
Glen Allen, VA 23058
Appeal Email: memberappeals@sentara.com
Grievance Email: complaints@sentara.com
Phone: (844) 434-2914
Fax: (866) 472-3920
Member Operations: (800) 881-2166
Authorizations:
Group Number VP
Existing Authorizations: Providers will experience no changes to authorizations that are approved and in progress, until further notice. The systems and guidelines supporting the authorizations for Group Number VP will remain the same. New authorization numbers will not be required on July 1.
New Authorizations: New authorizations are triggered by member eligibility. If Group Number VP member is eligible, use the existing authorization process you have used historically with Virginia Premier.
Joining the Network: New groups joining the network will join under Optima Health.
If you are interested in joining the LTSS network, please contact Centipede for additional information.
To Join Our LTSS Network
CENTIPEDE Health Network
Phone: (855) 359-5391
Fax: (866) 421-4135
Email: joincentipede@heops.com
CENTIPEDE Credentialing
CENTIPEDE Health
P.O. Box 291707 Nashville, TN 37229
Facility and Ancillary Providers: Contact Network Management at (877) 865-9075 to inquire about the contracting process.
To add a new provider to a practice, please submit a Provider Update Form. Please review the provider credentialing requirements prior to completing your submission.
Provider Manual Medicaid Supplement
Payer ID: VAPRM (all claims)
Optima Health
Claims Submission
Electronic - We accept claims through any clearing house that can connect through Payerpath/Allscripts or Availity.
Mail Paper Claims to:
- Medical Claims: PO Box 5028, Troy MI 48007-5028
- Behavioral Health Claims: PO Box 1440, Troy MI 48099-1440
Payer IDs:
54154 - Professional/Medical
5415M – Professional/Behavioral Health
00453 – Institutional
Timely Filing
- 365 days from the service date for all claims. This includes any corrections, reconsiderations, and/or appeals.
- Turnaround time for clean (correctly submitted) claims:
- Auto Adjudication 14 days
- Manual Adjudication 25 days
Reading an Optima Health Remit
View Claim Status and Submit Reconsideration Online
Appeals – May be submitted in writing within 365 days from the date of service for claims appeals. Clinical appeals must be submitted within 60 days of notice of denial. Detailed information and supporting written documentation should accompany the appeal. A decision will be rendered within 30 business days of receipt of the appeal request, with a 14-day extension if it is in the best interest of the member.
Mail to:
Optima Health Appeals and Grievances
PO Box 6253
Glen Allen, VA 23058
Appeal Email: memberappeals@sentara.com
Grievance Email: complaints@sentara.com
Phone: (844) 434-2914
Fax: (866) 472-3920
Member Operations: (800) 881-2166
Authorizations
- In office Lab List
- Formularies and Drug Lists
- Medical Authorizations and Reconsiderations
- Prescription Drug Authorizations
Sentara Brand Evolution
We are introducing our new name, Sentara Health, which reflects our enhanced focus on promoting the overall health and well-being of our consumers—our patients, members, and communities—who are at the center of everything we do. It also represents our deepening alignment between our healthcare services and health plans. We are practicing the future of healthcare today by providing healthcare that is simple, seamless, personal, and more affordable.
By the end of this year, we will retire the Optima Health and Virginia Premier brands unifying them under Sentara Health Plans. This change shows our steadfast commitment to our members and the communities we serve. The new brand identity is a representation of our growth and our promise to continue innovating and adapting in the ever-changing healthcare industry.
We will continue to go by the name people call us, Sentara, a name and brand our consumers trust.
While our brand is evolving, our mission remains the same: We Improve Health Every Day.