Optima Health Mental Health Coverage Guide
Optima Health is a Virginia-based health plan affiliated with Sentara Health, serving approximately 500,000 members. They offer individual, employer, Medicare, and Medicaid plans primarily in the Hampton Roads and Virginia regions.
How to Verify Your Mental Health Benefits
Before your first appointment, verify your specific benefits so you know what to expect. Here is a step-by-step process for Optima Health members:
- Call 1-800-206-1060 and have your member ID card ready.
- Ask to speak with the behavioral health benefits department.
- Ask: "What is my deductible for outpatient mental health services, and how much have I met?"
- Ask: "What is my copay or coinsurance for an in-network therapy session?"
- Ask: "Do I have out-of-network benefits, and what is the reimbursement rate?"
- Ask: "Is prior authorization required for outpatient therapy?"
- Ask: "Is there a session limit per year?"
- Ask: "Are telehealth sessions covered at the same rate as in-person?"
Know Your Rights: Mental Health Parity Act
Federal law requires Optima Health to cover mental health services at the same level as medical and surgical benefits. If you are denied coverage, ask for the denial in writing and reference the Mental Health Parity and Addiction Equity Act.
Want to keep track of all these details? Use our free benefits verification worksheet to organize your coverage information.
Finding an In-Network Therapist
Search Optima Health's provider directory directly: Find a therapist in your area
Tips for Using the Optima Health Directory
- Filter by "Behavioral Health" or "Mental Health" specialty.
- Check that the provider is accepting new patients before calling.
- Confirm the provider is in-network for your specific plan (not just Optima Health generally).
- Look for providers who specialize in your specific concern (anxiety, depression, trauma, etc.).
Types of Providers Covered
Telehealth Coverage
Optima Health covers telehealth therapy sessions, so you can meet with a therapist from home via video or phone.
Couples & Family Therapy
Family therapy covered with a qualifying diagnosis.
Understanding Your Optima Health Coverage
Available Plan Types
Prior Authorization
Not required for outpatient therapy.
Substance Use Treatment
Optima Health covers substance use disorder treatment, including outpatient counseling, intensive outpatient programs, and inpatient rehabilitation.
Common CPT Codes for Therapy
These are the billing codes your therapist will use when filing claims with Optima Health:
| CPT Code | Description |
|---|---|
| 90791 | Psychiatric diagnostic evaluation |
| 90834 | Individual therapy (45 minutes) |
| 90837 | Individual therapy (60 minutes) |
| 90847 | Family / couples therapy (with patient present) |
| 90846 | Family therapy (without patient present) |
| 90853 | Group therapy |
How to Get Reimbursed (Out-of-Network)
If you are seeing a therapist who is not in Optima Health's network, you may still be able to get reimbursed. Here is how:
- Pay your therapist directly at the time of your session.
- Request a superbill from your therapist after each session. This is a detailed receipt with the information Optima Health needs to process your claim.
- Submit your claim to Optima Health using one of these methods:
- Online: Submit through the member portal
- Mobile App: Submit via the Optima Health app
- Fax: 1-757-552-7412
- Mail: Optima Health, P.O. Box 5765, Virginia Beach, VA 23471
- Wait for processing. Most claims are processed within 30 days. You will receive an Explanation of Benefits (EOB) showing what was covered.
What Your Superbill Should Include
- Therapist's name, credentials, NPI number, and tax ID
- Date of service
- CPT code (e.g., 90834 or 90837)
- ICD-10 diagnosis code
- Amount charged
- Your name and date of birth
Optima Health tip: Submit via the Optima member portal. Sentara providers are in-network.
Save Money on Therapy with Optima Health
Use Your HSA or FSA
Therapy is an eligible expense for Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs). You can use these pre-tax dollars to pay for copays, coinsurance, and out-of-network therapy costs, effectively saving 20-35% on your therapy expenses.
Ask About Sliding Scale Fees
Many therapists offer reduced rates based on your income. If you have a high deductible Optima Healthplan or high out-of-pocket costs, ask your therapist about sliding scale options. Some therapists will also offer "single-case agreements" with Optima Health at a negotiated rate.