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Here you will find answers to common questions on a variety of topics. You can select one of the topics or questions below, or simply scroll down to read all of the questions and answers.
If you need answers to other questions, or need to ask about a specific plan and benefits, contact Member Services from 8 a.m. to 5 p.m. Monday through Friday at the phone number listed on your ID card or 757-552-7174 for general questions. The TDD line for the hearing impaired is 1-800-225-7784.
- Do I need a primary care physician (PCP) referral to access my behavioral health benefits?
- Do I need a referral from my primary care physician (PCP) to make sure my provider will be paid?
- Whose responsibility is it to contact Optima Behavioral Health for the initial authorization?
- Whose responsibility is it to provide information to Optima Behavioral Health for continued authorization after the initial authorization?
- What if I have stopped seeing my provider for a period of time and then want to return?
- What is an authorization?
- Can I use services that are not authorized by Optima Behavioral Health?
- Why does my provider have to send a treatment plan?
- What does "in network" mean in terms of my behavioral health provider, and how do I know whether or not he/she is participating with the my plan?
- How do I find behavioral health providers located in my geographic area?
- What do the letters after a behavioral health provider’s name mean?
- Why do I need to see a psychiatrist for medication?
- Who has access to my records? Can I be sure that the fact that I'm getting behavioral health treatment is kept confidential?
- Why can’t you talk to me about my spouse's, partner's or adult child's care? I’m the subscriber. It’s my policy!
- Why do you send mail to my 14 year old child?
- What is "behavioral health"?
- If I am hearing impaired or non-English speaking, how do I contact Optima Behavioral Health?
- What do behavioral healthcare managers do?
- Can you come see me in the community?
- How am I notified of an appeal decision?
- Do I need a Primary Care Physician (PCP) referral to access my behavioral health benefits?
No, but you may need pre-authorization. Contact us to get pre-authorization.
- Do I need a referral from my Primary Care Physician (PCP) to make sure my provider will be paid?
No, but you may need pre-authorization to use your behavioral health benefit. Contact us prior to your first appointment to get pre-authorization.
- Whose responsibility is it to contact Optima Behavioral Health for the initial authorization?
It is your (the member’s) responsibility. Contact us to get your initial pre-authorization.
- Whose responsibility is it to provide information to Optima Behavioral Health for continued authorization after the initial authorization?
Your behavioral health provider may obtain continued authorization by submitting an Individual Service Plan or Medication Treatment Report.
- What if I have stopped seeing my provider for a period of time and then want to return? If it has been more than 120 days since your last visit, you need to contact us for a new authorization. If it has been less than 120 days, contact Member Services to assure that your authorization is still current.
- What is an authorization?
An authorization is an agreement for Optima Behavioral Health to be responsible for reimbursement for behavioral health services. We provide authorizations based on the member’s Certificate/Evidence of Coverage that describes covered behavioral health benefits. In some cases, especially with a non-network provider (if you have an out of network benefit), the provider may bill you for any services provided that are not authorized by OBH. An authorization does not always guarantee payment as coverage depends on eligibility and other Plan conditions. Contact Member Services to determine the status of your authorizations.
- Can I use services that are not authorized by Optima Behavioral Health?
Lack of an authorization does not mean the member cannot receive the services requested. Treatment decisions are made by the member and his/her clinician. Authorizations only indicate services for which Optima Behavioral Health will provide payment. Anytime we make an authorization decision, whether it is to authorize or to not authorize a requested service, then we notify the member and the provider by letter. If you have any questions, please contact Member Services.
- Why does my provider have to send a treatment plan?
We review Individual Service Plan (treatment plan) to assure members are provided quality care, appropriate care, and services covered by their benefits.
- What does "in network" mean in terms of my behavioral health provider, and how do I know whether or not they are participating with my plan?
All network providers have been credentialed and contracted with Optima Behavioral Health and are considered to be "participating" with your plan. Visit Find a Behavioral Health search or contact Member Services for the most up to date information regarding your provider’s network participation.
- How do I find out which behavioral health providers are located in my geographic area? Contact Member Services.
- What do the letters after a behavioral health provider’s name mean? The letters represent the provider’s educational degree and/or their state licensure. Terms You Should Know includes a complete listing of professions licensed for your state.
- Why do I need to see a psychiatrist for medication? Some Primary Care Physicians (PCPs) prescribe psychiatric medication. However, psychiatrists are specialist medical doctors and the only behavioral health care providers licensed to dispense medications. Psychologists and other licensed professionals are not licensed to provide medication.
- Who has access to my records? Can I be sure the fact I'm getting behavioral health treatment is kept confidential?
Your treatment records are maintained at your provider’s office. We occasionally review records at random to assure high quality documentation. We review treatment plan summaries provided by your provider. Any clinical information we review is done only by licensed clinical staff who are bound by state and federal law to preserve your confidentiality. We do not disclose to anyone that you are receiving behavioral health treatment without your written permission.
- Why can’t you talk to me about my spouse's, partner's, or child’s care? I’m the subscriber. It’s my policy!
By law, we are required to protect a member's health information and may only provide information to individuals for whom the member has provided
written permission.
- Why do you send mail to my 14-year-old child?
By law, we must protect health information and treatment related of children 14 years and older. Therefore, when we need to send written information about a 14-year-old or older behavioral health authorization or treatment, we send it directly to the child.
- What is "behavioral health?"
Behavioral health refers to evaluation and therapy services used in the treatment of mental health and substance abuse problems.
- If I am hearing impaired or non-English speaking, how do I contact Optima Behavioral Health? For hearing impaired members, a TDD line is available by calling 757-553-7120. Non-English speaking members may call Member Services to access the AT&T Language Line (800) 874-9426 for an interpreter.
- What do behavioral healthcare managers do?
They work with members, providers, facilities, and programs to assure that our members receive needed behavioral health services in the least-restrictive setting possible. They do this work through telephone calls and reviewing written documents. They are knowledgeable about the member’s benefits, and available clinicians, facilities and programs. In addition, they are knowledgeable about resources available in the community and through other agencies that may not be covered by the benefit but may be helpful to our members.
- Can you visit me in the community?
Our care managers only work directly with members by telephone. The treating providers have direct contact with the members in care. The care managers are a resource to the treating providers.
- How am I notified of an appeal decision?
You will be notified in writing by U.S. mail within 72 hours of initiation of an urgent appeal and within 60 calendar days for routine appeal.
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