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Optima Behavioral Health has a formal process that allows for your concern to be addressed with the appropriate departments/persons within Optima Behavioral Health. The complaint and appeals process is part of our Member Service Program and are managed and monitored by a licensed clinician.
If you have a problem or concern about Optima Behavioral Health and/or the quality of care, services and/or policies and procedures of Optima Behavioral Health, contact Member Services. Research into your concerns is conducted in a timely manner to accommodate any clinical urgency of the situation. Upon research and completion, you will be notified of the resolution to your concern.
If your concern involves a denial of a covered service or claim, Optima Behavioral Health has a formal appeals process. Adverse authorization, claim payment, and benefit decisions can be appealed. Our reviews are conducted in a timely manner to accommodate the urgency of the concern.
Appeals involving clinical matters are reviewed by a board certified psychiatrist, or other appropriate doctoral level licensed clinician(s), who were not involved in the decision leading to the dispute. Appeals involving administrative matters are reviewed by our Appeals Manager.
You may be eligible for a routine appeal or an expedited appeal if an emergency behavioral health condition exists. An appeal may be either routine (written decision within 14-60 days) or expedited (urgent situations requiring a decision within 72 hours). Contact us to initiate a complaint or general review. You can also download additional information on the appeal process, including an appeal request form (PDF file). Optima Medicare members can download information on the Medicare Appeal Process.
No other internal appeal rights are available with Optima Behavioral Health. However, there may be a final external review, after the Optima Behavioral Health process is complete. In the event of an unfavorable adverse appeal decision, the member is notified of any additional appeal rights.
To request an appeal review, send written requests to Optima Behavioral Health.
By regular mail:
Optima Health
Appeals Department
P.O. Box 62876
Virginia Beach, VA 23466-28762
In person:
Optima Health
4417 Corporation Lane
Virginia Beach, VA 23462
By fax:
757-552-7176 Fax
888-576-9675 Fax Toll Free
For more information about our member appeal process, contact Member Services.
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