Virginia Beach, VA 23462
1-844-512-3172 or 1-800-229-8822
OHCC, DSNP and OFC
Authorization status can be checked at optimahealth.com or by
calling Provider Relations.
Government Programs: Authorization Request for
Behavioral Health Outpatient Services
Optima Community Complete (DSNP)
Optima Health Community Care | Optima Family Care
_________________________________________
Please submit via fax to 757-963-9620 or 1-844-895-3231
Member Name / Last, First Member ID / Policy # Date of Birth / Age
□ ECT □ rTMS □ Behavioral Health Procedure
Date of Service____/____/____
Provider Information
Requesting Provider: _________________________________Specialty: _____________________
Optima Provider #____________________NPI # ______________________ Tax ID # ___________________
Phone: __________________ Fax: ______________
The below information and pertinent medical notes are required to process your request:
Diagnosis Codes: /Diagnosis:_____________________________
Procedure Codes:
_______________/_________________/_________________/________________/___________________
Procedure Description:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Provider Group
Tax ID # ___________________ NPI # ______________________
Person Completing Form: _________________________Phone: __________________ Fax: ______________
Authorization is not Guarantee of Payment
