UVA Health Plan Ombudsman FAQ

Answers to your frequently asked questions are listed below with links to resources you may need listed at the bottom of the page.

What are some ways I can get the most cost-effective use out of my health plan benefits?

Here are some tips to ensure your health care choices will be cost-effective:

  • Be sure to select the UVA Health Plan option that will best meet your needs. See the schedule of benefits for Basic, Value, and Choice Health for more specific information.
  • Medical visits to UVA Health System Providers have lower copayments.
  • When choosing care providers, determine if they are in or out of the Aetna network using the participating provider directory (link in Resources below). Your costs for using out-of-network providers work differently than in-network. In-network providers agree to Aetna’s allowable amount to charge for health services. Out-of-network providers have not made this agreement. The difference between what they charge and what Aetna allows for the service becomes your responsibility, and this amount may be substantial. Be aware of the potential impacts of choosing an out-of-network provider prior to receiving services.

How do I get a replacement insurance card?

Visit the benefit provider’s website or contact their member services to get a replacement card.

Why was I charged for a lab test my doctor ordered as part of my yearly physical exam?

For annual physical exams, including lab tests, costs your provider codes as preventative will be covered at 100%. Some tests cannot be coded as preventative because their purpose is to check on an existing condition. Others cannot be considered preventative at any time, even if ordered as part of a routine physical.

A prescription medication I need to take has been denied by Optum for prior authorization. What should I do?

Ask your physician to contact Optum to request prior authorization. Optum will fax the doctor a specific form for the drug requiring prior authorization for the physician to complete and return. Once approved, your authorization will be on file at Optum, and you can get your prescription. A similar process is in place for medications requiring step therapy or for quantity limitation override requests. The physician can call the Optum prior authorization department to have a form faxed to them, or the physician can do an urgent verbal appeal. See the Filing Complaints and Appeals page, accessible via the upper left-hand menu, for contact details.

My doctor ordered me a brand-name medication. At pickup, I was told my copay would be very expensive. How can this be?

When a UVA Health Plan member uses a prescription drug card to obtain a brand-name medication, you pay the difference between the cost of a similar generic medication and the higher cost of the brand-name drug. This higher cost is referred to as a Dispense As Written penalty, or DAW. Physicians can appeal the DAW penalty if they believe the brand-name medication is medically necessary. See the Filing Complaints and Appeals page, accessible via the upper left-hand menu, for contact details.

My preauthorization was denied for a procedure my doctor says I should have. What can I do?

You do have appeal rights, described in detail in the Summary Plan Description (link below in Resources). Your physician may call Aetna for a peer-to-peer review if a claim or preauthorization request is denied. If this review results in the procedure remaining denied, you may proceed with the appeal process for decisions based on medical necessity. See the Filing Complaints and Appeals page, accessible via the upper left-hand menu, for contact details.

How can adult children or spouses give permission for the Health Plan to speak with a family member or friend about their health claims?

Complete a UVA Health Plan Health Insurance Portability and Accountability Act (HIPAA) authorization form and send the form to the UVA Health Plan Ombudsman by fax, email (as attachment), or mail. Form and contact information in Resources below.

What is the working-spouse provision?

Working spouses with coverage through their own, non-UVA employer are ineligible for UVA coverage as long as their employer-provided insurance is affordable and provides minimum value as defined by the Affordable Care Act. A working spouse whose plan elsewhere is insufficient may still be eligible for coverage on the UVA Health Plan. Use the Affordability Standard Calculator available in Resources to help determine if employer-based coverage meets the affordability standard.