Common Questions

Questions About CalOptima Direct

Below are some common questions and answers about CalOptima Direct. If you do not see your question answered here, please call our Customer Service Department. We are here to help you and make sure you get access to the best health care possible.

  1. How do I check on an authorization request submitted by my doctor or specialist?
  2. What do I do if I get a bill for health care services?
  3. What do I do if I have other health insurance?
  4. What should I do if I need care after my doctor’s office hours?
  5. How do I get emergency or urgent care if I am outside of Orange County?
  6. What is the Medi-Cal Benefits Identification Card (BIC)? What is the CalOptima ID card?
  7. What if I lose my ID card?
  8. How do I get mental health services?
  9. What medications are covered?
  10. How do I get prescription coverage if I am outside of Orange County?
  11. How do I get dental care services?
  12. How do I get vision services?
  13. What if my name changed, I moved or I have a new phone number?
  14. What if I need to speak to my doctor in my language?
  15. How do I reach CalOptima’s Customer Service Department?

Your doctor or specialist should let you know when a decision has been made. You can also check on the authorization request by calling CalOptima’s Customer Service Department.

Call the provider who gave the health care service you were billed for. Give the provider your CalOptima (Medi-Cal) and/or other insurance information. If you get another bill or are in collections, contact CalOptima’s Customer Service Department for help.

Your other health insurance is the primary payer and is responsible for covering the services you received. CalOptima (Medi-Cal) is the last payer. You will need to ask for payment for services through your primary insurance before CalOptima (Medi-Cal) will pay.

After-hours care is when you need medical attention after your doctor's office is closed.

If you need after-hours care:

  • Call your doctor or CalOptima’s Customer Service Department. You should be able to speak to a nurse or someone who can give you medical advice within 30 minutes of your call. You may be asked to go to an urgent care center or to the hospital emergency room.
  • Show your ID cards when you get after-hours care.
  • Interpreter services are available to you 24 hours a day/7 days a week at no cost to you.

If you are outside of Orange County and have an emergency or need urgent care:

  • Call 911 or go to the nearest hospital emergency room or urgent care center.
  • If you are not sure if it is an emergency or if you need urgent care, call your doctor or CalOptima’s Customer Service Department.
  • Show your ID cards when you go to the hospital emergency room or urgent care center.
  • Ask the hospital or urgent care center staff to call CalOptima within 24 hours.

Do not go to the hospital emergency room for general health care services. Call your doctor for general health care services.

The BIC is a card issued by the County of Orange Social Services Agency. This card is used to obtain Medi-Cal covered services.

The CalOptima ID card is issued by CalOptima. This card helps to identify you as a CalOptima member. It is important to have all health insurance cards with you and present them to your provider when you access health care services.

If you lose your BIC, call or visit your local County of Orange Social Services Agency. Click here for a list of offices.

If you lose your CalOptima ID card, call CalOptima’s Customer Service Department.

Psychiatry and psychology services are covered through county mental health programs. Members can access benefits through Orange County Mental Health Plan by calling toll-free 1-800-723-8641.

CalOptima has a list of medications that are covered (paid for) by CalOptima.
This list is called the Approved Drug List or Drug Formulary. CalOptima pays for medications on this list when they are filled at one of CalOptima’s network pharmacies. CalOptima’s Pharmacy Directory is included in all new member packets.

If your doctor writes a prescription for a medication that is not on CalOptima’s Approved Drug List, your doctor or pharmacy must ask for approval. The approval request form is called a Prior Authorization (PA) form. All CalOptima network pharmacies have this form. Your pharmacy sends the form to your doctor.
Your doctor completes the form and sends it back to the pharmacy to submit
to CalOptima.

In California, you can go to any participating chain pharmacy. Prescriptions filled outside of California need prior approval from CalOptima. Chain pharmacies are listed in the CalOptima Pharmacy Directory.

If you have questions, call CalOptima’s Customer Service Department.

Denti-Cal provides dental care for members under the age of 21, an adult living in a nursing home or in an Intermediate Care Facility for the Developmentally Disabled (ICF-DD Habilitation and ICF-DD Nursing). To contact Denti-Cal, call toll-free at
1-800-322-6384.

Vision care services are provided to eligible CalOptima members through Vision Service Plan (VSP). To find out if you are eligible, please call CalOptima’s Customer Service Department, 1-714-246-8500 or toll-free at 1-888-587-8088, Monday through Friday from 8 a.m. to 5:30 p.m. We have staff who speak your language. TDD users can call 1-714-246-8523.

We need your correct name, address and phone number to contact you about your health care. If you have a new name, address or phone number, you will need to report it by calling:

  • Your Orange County Social Services Agency eligibility worker or the Social Security Administration
  • The United States Post Office at 1-800-275-8777
  • CalOptima’s Customer Service Department

If you have questions, call CalOptima’s Customer Service Department.

You can speak with your CalOptima health care providers in the language of your choice. Many of our providers and staff speak your language. Our over-the-phone interpreter service is available to you 24 hours a day.

You can also ask for a face-to-face interpreter for your health care services. You do not have to ask family members or friends to interpret for you. For example, you can ask for an interpreter to be with you at your doctor visit if your doctor or the office staff does not speak your language. You need to ask for an interpreter at least five (5) working days before your doctor’s appointment or at the same time you make your doctor’s appointment.

If you feel your language needs are not being met, you can file a complaint with CalOptima. For help with interpreter services, call CalOptima’s Customer Service Department.

You can reach CalOptima’s Customer Service Department by calling 1-714-246-8500 or toll-free at 1-888-587-8088, Monday through Friday, from 8 a.m. to 5:30 p.m. We have staff who speak your language. TDD users can call 1-714-246-8523.

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