If you disagree with the decision or explanation given to you by the customer service representative or if you have a complaint about any other issue regarding your insurance you may request a grievance review. Superior has updated our claims system to reimburse the updated fee schedule rates: Personal Care Services. Within five (5) business days after receiving a notice of decision from the independent review organization, the director shall mail a notice of the decision to Superior Vision, the health insurer, the member and the members treating provider. Their eye care solutions are comprehensive, and on average, provide savings of 20% or more on eye-related costs. We reserve the right at any time and periodically to modify this site, temporarily or permanently, or any part thereof, with or without notice. The Exclusive Collection. Download the data file or print your PDF version. NGLIC contracts with Superior Vision Services, Inc. to provide access to their network of vision care providers. Publications in PDF can be viewed and printed using the Adobe Acrobat Reader or other PDF readers. In most cases, LASIK is performed on both eyes and completed within minutes. 2022 Versant Health Holdco, Inc. (Versant Health). Ifyou believe that this page should betaken down, please follow our DMCA take down process, Ensure the security ofyour data and transactions, Superior Vision Reimbursement Form Online, TRIGONOMETRI EQUATIONS PART 1 Of 1.MDI - Teko Classes Bhopal, Stokes Stitt Scholarship Program - The Reading Housing Authority, ASITIA Permission Letter - Rutherford County Schools - Blm Rcs K12 Tn, Botswana Public Officers Pension Fund Forms. Medicare, Medicaid, CHIP, Tricare, Health Insurance Marketplaces, Language Assistance Program, Language Assistance: Espaol | | Ting Vit | | Tagalog | | | Deutsch | | | Other Languages. As some content on this site is provided by other organizations and web content providers, Superior Vision cannot and does not guarantee the accuracy, timeliness and/or source of information from these organizations. Inappropriate use of a modifier or using a modifier when it is not necessary will result in denial or a delay of claim reimbursement. Superior Vision Attn: Claims Processing P.O. Superior Vision is a product offering from Versant Health, a company forged from the experience of two leading vision care plans. The health care insurer shall provide any service or pay any claim determined to be covered and medically necessary by the independent review organization for the case under review regardless of whether the judicial review is sought. Subscriber Information Please print clearly Subscriber Name Daytime Phone Evening Phone Mailing Address City State Name of Employer Zip Patient Information Patient Name Date of Birth Authorization Number Full Time Student Yes // No Verification may be required Claim Information Single Vision Lenses Bifocal Lenses Progressive Lenses Date of Service Exam Frame Is the provider an in-network provider Provider Name Contacts Contact Lens Fitting Exam Extra Ad-Ons Other Phone Number If you saw an in-network provider Are you applying for reimbursement after using an in-store sale or promotion you pay in full and then submit your receipt to Superior Vision for reimbursement at the out-of-network rates. Tambin podemos proporcionarle material en espaol acerca de sus beneficios. The name and identification number of the member asking for the review; Names of health care providers or administrative staff involved; and. Superior Vision Reimbursement Form Online Get Superior Vision Reimbursement Form Online How It Works Open form follow the instructions Easily sign the form with your finger Send filled & signed form or save superior vision reimbursement rating 4.8 Satisfied 49 votes The Superior Vision website takes advantage of several advanced Internet and browser technologies to create the best possible user experience. Superior Vision makes no guarantee as to the content found on other sites. We work to make our PDFs accessible for use with assistive technology such as screen readers like JAWS and NVDA. In the event of a denial of a claim for a service that has already been provided, the member may request, either orally or in writing, an informal reconsideration by notifying Superior Vision within two (2) years after the receipt of the notice of denial. professionals who participate in your plan. View Top 10 List Ensuring members easy access to quality care with Superior Vision can help drive improvements in HEDIS/Stars scores. To proceed with learning more about Versant Health, please click on the button below. Comply with our easy steps to have your Superior Vision Claim Form prepared quickly: Take advantage of the fast search and innovative cloud editor to make a correct Superior Vision Claim Form. Try eliminating some of the search information. We will help you get the help you need. For immediate situations where a member may have lost or damaged his or her contact lenses or eyeglasses and the member is out-of town, a customer service representative may facilitate directing the member to a contracted provider in the area. Learn More About Our Routine Vision Care Services In addition to the information below, you can email our privacy officer at. Download Form OptumHealth Vision / United Healthcare. Thank you in advance for helping us with our continued improvement to serve you better. Author: If you have not yet completed the new registration, please do so nowyou'll be done in the blink of an eye! California Confidentiality of Medical Information. Wellness Center Davis Vision Vision Care Plan Processing Unit P.O. You may email us the completed forms or bring them with you on your next visit. . Use your browsers print option. The SSL security protocol provides data encryption, server authentication, and message integrity for your connection. Tip: Missing information and receipts can delay your reimbursement. Customer Service: 800-507-3800 . The Superior Vision Plan is a vision care program designed to offer a high-level of vision care to you and your family. If you answered No to question 2, please note Superior Vision Network Providers should only collect for Copayments and/or Non-covered items at the time of service. Box 967 u Rancho Cordova u California 95741 u 800-507-3800 u www.superiorvision.com . Simply call Superior Member Services. Act preventively and schedule regular comprehensive eye exams. To zoom out press CTRL + MINUS SIGN (-). We update our website data several times each month, changes in account information may not be reflected immediately, if you have a concern with an account update please contact. If there is every a question about accuracy, please contact us through the website or at (800) 507-3800. Superior has updated our claims system to reimburse the updated fee schedule rates: Please review the Texas Medicaid and Health Partnership (TMHP) Online Fee Schedule for updated fee schedule reimbursement rates. We collect Click-stream data, HTTP Cookies. Box 967 Rancho Cordova, CA 95741 Phone: 1 (800) 507-3800 www.superiorvision.com. Thank you. Customer service representatives are trained to respond to calls quickly, resolve problems promptly and exercise sensitivity. This data will be given to ourselves and our agents. Welcome to the Superior Vision Plan. For more information, please review the following article: Therapy Fee Schedule Reimbursement Rates. We are currently experiencing technical issues impacting our service operations, including our member and provider portals. If you believe you have a vision problem or condition, contact a qualified vision care professional immediately. If you disagree with the decision or explanation given to you by the Customer Service Representative or if you have a complaint about any other issue regarding your insurance, you may request a grievance review. Our HIPAA Compliancy Statement can be found here. Apply your electronic signature to the PDF page. Superior Vision is a registered trademark of Versant Health Holdco, Inc. AbileneTexas Midwest Eyewww.txmidwesteye.com(325) 670-3937, AustinEye Physicians of Austinwww.eyephysiciansofaustin.com(512) 583-2020, Dallas / Ft. WorthUT Southwestern Medical Center Laser Center for Vision Carewww.utswlasik.com(888) 663-2020, GalvestonUTMB Health Eye Centerwww.utmbeyecenter.com(281) 687-7022, HoustonUT Houston Medical Center Robert Cizik Eye Clinicwww.cizikeye.org(713) 559-5200, LubbockTexas Tech Laser Vision Institute(806) 743-7777, TylerEyeCare Associates of East Texaswww.eyecaretyler.com(903) 595-0500. This policy is for when members have questions or concerns about the quality of vision care that they receive, or have an issue with a claim. Call 1 (877) 201-3602 for a free LASIK consultation. We do this through a broad-based provider network comprised primarily of board-certified ophthalmologists (MD), complemented by optometrists (OD), opticians, and optical companies who are responsible for delivering quality services. Contact Us. The carrier for the NDPERS Vision Plan is Superior Vision. Phone (800) 507-3800. Subscriber Information Please print clearly Subscriber Name Daytime Phone Evening Phone Mailing Address City State Name of Employer Zip Patient Information Patient Name Date of Birth Authorization Number Full Time Student Yes // No Verification may be required Claim Information Single Vision Lenses Bifocal Lenses Progressive Lenses Date of Service Exam Frame Is the provider an in-network provider Provider Name Contacts Contact Lens Fitting Exam Extra Ad-Ons Other Phone Number If you saw an in-network provider Are you applying for reimbursement after using an in-store sale or promotion you pay in full and then submit your receipt to Superior Vision for reimbursement at the out-of-network rates. This section provides information about commonly used modifiers for Vision Care providers. We can also provide member benefits materials to you in Spanish. For a complete list of modifiers, refer to the Modifiers: Approved List section in this manual. JavaScript and style sheets to enhance the appearance and functionality of the site. Written resolution of the grievance review will include the specific information considered and an explanation of the basis for the decision. Effective for dates of service on or after September 1, 2019, the Medicaid-implemented fee schedule changes for Medicaid services are listed below. Superior Vision is a product offering from Versant Health, a company forged from the experience of two leading vision care plans. Superior Vision Services, Inc. Notice of Privacy Practices, Superior Vision Services, Inc. Privacy Notice, Superior Vision of Texas Notice of Privacy Practices, Superior Vision of New Jersey, Inc. Notice of Privacy Practices, Superior Vision of New Jersey, Inc. Privacy Notice, Superior Vision Insurance Plan of Wisconsin, Inc. Notice of Privacy Practices, Superior Vision Insurance Plan of Wisconsin, Inc. Privacy Notice, Superior Vision Benefit Management, Inc. Notice of Privacy Practices, Superior Vision Benefit Management, Inc. Privacy Notice, Superior Vision Services, Inc. Notice of Privacy Practices New York, Superior Vision Services, Inc. Privacy Notice New York, https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, http://www.hhs.gov/ocr/office/file/index.html, Medicare, Medicaid, CHIP, Tricare, Health Insurance Marketplaces, Language Assistance Program, Language Assistance: Espaol | | Ting Vit | | Tagalog | | | Deutsch | | | Other Languages, Address of eye care professional (street, city, state). The preferred option is to send your Grievance in writing (company specific form is not required) to: If you choose you may fax it to us at: 916-852-2290, or. Eliminate the routine and produce paperwork online! SVS-PRO10-001 v005 02/2014. Denial upheld If we continue to agree that the covered services or claim for a covered service should have been denied, the complainant will receive a written notice of that decision. Denial Reversed If we agree that the covered services should have been provided, or that the claim should have been paid we will authorize the service or pay the claim. All completed forms will be filed in the FTP access folder maintained in the IS Department. If these technologies are not available, our page design helps ensure graceful degradation. Materials co-pay applies to lenses and/or frames, not contact lenses. Call Superior Vision Customer Service at (800) 507-3800, and someone who speaks your language can help you. P.O. Internet Explorer: Select Tools > Internet Options > General dialog page, and the Colors button. Scheduling an appointment and understanding your benefits is simple. To submit a practitioner application to CAQH, go to the CAQH website. Reimbursement Rate Changes. All information presented on the Superior Vision website is provided solely for general consumer understanding and education. Superior Vision shall mail a written acknowledgement to the member and the members treating provider within five (5) business days after Superior Vision receives the formal appeal. Emergency Medical Condition means the sudden, and at the time, unexpected onset of a health condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: Grievance means a written complaint submitted by or on behalf of Covered Person regarding: Insurer means the insurance carrier underwriting the Superior Vision Plan. Details of the attempt that was made to resolve the problem. If you do not already have AdobeReader installed on your computer, Click Here to download. We strongly advise members to always seek the advice of a vision/eye care professional with any questions about vision and eye care or any medical condition. If Superior Vision concludes that the covered service should be provided or the claim for a covered service shall be paid, the health insurer (NGLIC) is bound by Superior Visions decision. Superior Vision, bajo el Programa de Asistencia Lingstica (LAP, por sus siglas en ingls), provee el servicio gratuito de interpretacin a nuestros miembros que prefieren contactarnos en espaol. This includes uploading and downloading files. Select Find an eye care professional from the top of any page. USLegal has been awarded the TopTenREVIEWS Gold Award 9 years in a row as the most comprehensive and helpful online legal forms services on the market today. For Urgent medical conditions, members are instructed to contact their Medical Plan or Provider or local UCC. For Emergency Medical Conditions situations, members are directed to contact their local EMC, or call 911. Superior Vision - Coronavirus update to eye care professionals. However, on December 15, 2016, HHSC is changing its Medicaid fee schedule for therapy services. It is best viewed with Java Script enabled. If you are a group that wants to participate in the file exchange program you will need to fill out online request form and submit it to the IS Department at Superior Vision Services for review. Date: 10/01/19. Superior Vision is a vision insurance company focused on providing quality eye care and treatment, rather than simply offering savings on eyewear. Member Reimbursement Claim Form Use this form for reimbursement for services received from an out-of-network provider or when you ve utilized an in-store sale or promotion from an in-network provider. We invite you to experience the highest quality of care while taking advantage of the discounts offered to Superior Vision Services members. Subscriber Information Please print clearly Subscriber Name Daytime Phone Evening Phone Mailing Address City State Name of Employer Zip Patient Information Patient Name Date of Birth Authorization Number Full Time Student Yes // No Verification may be required Claim Information Single Vision Lenses Bifocal Lenses Progressive Lenses Date of Service Exam Frame Is the provider an in-network provider Provider Name Contacts Contact Lens Fitting Exam Extra Ad-Ons Other Phone Number If you saw an in-network provider Are you applying for reimbursement after using an in-store sale or promotion you pay in full and then submit your receipt to Superior Vision for reimbursement at the out-of-network rates. To optimize your experience on the Superior Vision website, your system must meet the following software requirements: Clinical Policy 1309 Medically Necessary Contact Lenses Effective 4.1.22, Clinical Policy 1309 Medically Necessary Contact Lenses Effective 1.1.23, Clinical Policy 1309 Medically Necessary Contact Lenses Effective 1.1.23 Spanish, Clinical Policy 1309 Medically Necessary Contact Lenses Spanish Effective 4.1.2022, Clinical Policy 1310 Refraction Effective 2.1.22, Clinical Policy 1310 Refraction Effective 2.1.22 Spanish, Clinical Policy 1316 Eye Exams_Effective 5.1.2022, Clinical Policy 1330 Specialty Spectacle Lenses Effective 7.1.22, Clinical Policy 1336 Telemedicine Effective 7.1.2022 Spanish, Clinical Policy 1336 Telemedicine Effective 10.1.2022, Clinical Policy 1336 Telemedicine Effective 10.1.2022 Spanish, 455A.02 Texas Consistency of Application of Clinical Criteria, 456A.02 Texas Clinical Criteria for Utilization Management, 483A.01 TX HMO Notification of Non-Behavioral Health UM Determinations. Your request for a grievance review should include: A Grievance may be submitted to us by or on behalf of a Covered Person within one year of the date of treatment, event or circumstance giving rise to the Grievance, such as the date of the claim denial. You do not need to fill in all blanks. Contact Information Fax: 855-313-3106Phone: 888-273-2121Email: ecs@superiorvision.comProvider Portal Superior Vision Provider Routine Vision References The Superior Vision (Versant) routine vision references provide information on topics . But for anti-scratch coating, you only get discounts. Cookies are a technology which can be used to provide you with tailored information from a website. Superior Vision Services, Inc. u P.O. Call Superior Vision Customer Service at (800) 507-3800, and someone who speaks your language can help you. Contact lenses Once your request is received, we will research the case in detail, ask for more information as needed and let you know, in writing, of the decision or the outcome of the investigation into your case. Serious dysfunction of any of the members bodily organs or parts. Office Hours: 8:00 a.m. to 5:00 p.m. CST / 8:00 a.m. to 6:00 p.m. CST (STAR Health only) After office hours, Superior's STAR Kids nurse advice line staff is available to answer questions and intake requests for prior authorization by calling 1-844-590-4883. Declaracin de Privacidad en Espaol esta aqu. We will follow our standard business practices guidelines when resolving your problem or concern. ERISA provides that if your claim for a welfare benefit is denied, in whole or in part, you have the right to know why this was done, to obtain copies of all documents relating to the decision without charge, and to contest any denial, all within certain time schedules. 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