State of Texas Vision c/o Superior Vision, Administrators Attn: Claims Processing 11090 White Rock Road Suite 175 Rancho Cordova, CA 95670. If deemed necessary and appropriate, your grievance may be forwarded to our CQI program. The Network Provider will bill Superior Vision directly for all covered services. Upon request, your provider shall we will sent a copy of this grievance and appeals notice within five (5) business days after the date the appeal is initiated pursuant to an expedited medical review, expedited appeal, informal reconsideration and/or formal appeal. We are currently experiencing technical issues impacting our service operations, including our member and provider portals. If you are looking for an eye doctor or need assistance in choosing one nearest you, you may call the customer service toll-free telephone number shown on your ID card, or visit the Superior Vision Services website: superiorvision.com. We work to make our PDFs accessible for use with assistive technology such as screen readers like JAWS and NVDA. As some content on this site is provided by other organizations and content providers, Superior Vision cannot and does not guarantee the accuracy, timeliness and/or source of information from these organizations. SUPERIOR VISION See yourself healthy. If at the conclusion of the formal appeal process Superior Vision denies the appeal and Superior Vision does not initiate the external independent review process, Superior Vision shall provide the member with notice of option to proceed to an external independent review. Try eliminating some of the search information. Llame al Centro del Servicio al Cliente al 1.800.507.3800, y alguien que habla su idioma lo ayudara. Providers must use the appropriate Current Procedural Terminology (CPT 1) codes or Healthcare Common Procedure Coding System (HCPCS) codes when submitting claims for vision services to the IHCP. 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. To send a claim by paper, please mail claim forms to: Superior HealthPlan, Attn: Claims, P.O. Any person making an oral complaint will be instructed to document his or her concerns and to submit a formal Grievance in writing to us at the address above. If you paid in full for your service please provide a brief explanation as to why your provider did not bill us on your behalf. Date: 10/01/19. Vision Plan Out-of-Network Claim Form Please return this form with a copy of your paid, itemized receipt to: UnitedHealthcare Vision ATTN: Claims Department P.O. PDF VISION FEE SCHEDULE effective 01/01/2020 Print Date: 2/4/20 Price does If you call seeking services for an Emergency or Urgent Medical Condition, or an immediate situation a customer service representative will direct you as follows: If you have a problem or concern, you should first call the Superior Vision Plan customer service toll free number shown on your ID card. Aperture (the CVO services provider) will assist with a provider's credentialing process for Superior HealthPlan. Because this site, and all content comprising the site, is for educational purposes only, there is nothing on the site that is or should be considered, or used as a substitute for, medical advice, including advice about vision and eye care and/or any issues related to vision and eye care. We strongly advise users to always seek the advice of a vision/eye care professional with any questions about vision and eye care or any medical condition. Site - Document Library. Alternative text for images and other non-text elements. Form fields with associated labels and error messages to assist with completing the form. A comprehensive eye exam can lead to an early diagnosis of health issues or systemic diseases such as diabetes, high cholesterol, hypertension, macular degeneration and glaucoma. Superior Vison Claim Form. Vision Insurance | MetLife Vision Use professional pre-built templates to fill in and sign documents online faster. Each Virtual Private Servers resides in a protected sandbox with 24/7 monitoring. Superior Vision Plan offers one of the largest networks of vision care providers. Enjoy smart fillable fields and interactivity. Please call our Customer Service department at 800.507.3800 . California Confidentiality of Medical Information. At Superior Vision, we offer patient forms online so you can complete them in the convenience of your own home or office. If Superior Vision initiates the external independent review process, Superior Vision does not have to comply with section E. (above). Credentialing documents are submitted to Aperture through CAQH or Availity. Guarantees that a business meets BBB accreditation standards in the US and Canada. JavaScript and style sheets to enhance the appearance and functionality of the site. For security reasons the data that is used to build the Web pages is not taken from Superior Vision Services live database. You can enter a new search by hitting the New Search image. 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. It starts with our network. CLAIM ONLINE Members can submit an out-of-network claim through the secure Member Portal on SuperiorVision.com. Written resolution of the grievance review will include the specific information considered and an explanation of the basis for the decision. 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. 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 . 10/01/19. 2022 Versant Health Holdco, Inc. (Versant Health). Superior Vision Classic Plan: It covers annual eye exams at a $15 copay and eyewear materials (frames and lenses) at a $25 copay. Therapy Fee Schedule Reimbursement Rates - Superior HealthPlan Envolve Vision The time frame to complete our review may be extended if we and you agree additional time is required to fully investigate and respond to the Grievance. Vision insurance is issued by Metropolitan Life Insurance Company, New York, NY. We reserve the right at any time and periodically to modify this site, temporarily or permanently, or any part thereof, with or without notice. . Superior vision provides a $125- $200 frame allowance and covers in full single vision lenses, lined bifocals, and lined trifocals. Box 967 Rancho Cordova, CA 95741 Questions? Serious dysfunction of any of the members bodily organs or parts. Superior Vision: The Superior Vision supplier diversity program is a good faith sourcing effort designed to match qualified diverse suppliers with the needs of our internal business partners, create business opportunities for diverse suppliers to support Superior Vision, and build long-term business relationships with individuals that are reflective of our communities. After a decision is made pursuant to sections E, F, G or K, the reconsideration, appeal and administrative processes are completed and the departments role is ended, except: A decision made by the director or an independent review organization pursuant to this section is admissible in proceedings involving a health care insurer or Superior Vision. When timed response is required, the user is alerted and given sufficient time to indicate more time is required. You are also responsible for paying for any services or materials that are not covered or that exceed your benefit plan coverage. For Emergency Medical Conditions situations, members are directed to contact their local EMC, or call 911. The term Covered Person includes a representative duly authorized in writing to submit a Grievance on behalf of the Covered Person. But for anti-scratch coating, you only get discounts. We will let you know that your request was received by sending you a confirmation in writing or by email (if address is provider) within 15 business days. 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. The Superior Vision Plan is a vision care program designed to offer a high-level of vision care to you and your family. Cookies are used for the following purposes: As part of our effort to provide Superior Service, we strive to make our products and services accessible to all users, including individuals with disabilities. Davis Vision . Access the most extensive library of templates available. Depending on your benefit coverage, a LASIK discount or allowance may be included. In addition to the information below, you can email our privacy officer at. Thank you! 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. Why Superior Vision? 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). I am . Superior Vision seeks to provide opportunities to qualified diverse suppliers, including minority-owned, woman-owned, historically underutilized business zone (HUBZone), service-disabled veteran-owned, veteran-owned, small businesses and other disadvantaged business enterprises in the communities in which we operate and serve. We are currently experiencing technical issues impacting our service operations, including our member and provider portals. Superior Vision - Members Internet Explorer: Select Tools > Internet Options > General dialog page, and the Colors button. We test content for accessibility during production and are constantly working to improve our website accessibility. Call 1 (877) 201-3602 for a free LASIK consultation. I completed the reimbursement form and mailed it along with a copy of the Contacts Direct receipt to Superior Vision on 4/1. We will use every opportunity to be reasonable in find a solution that makes sense for all parties. Medical reimbursement and dependent child care: Southern Administrators and Benefit Consultants, Inc. Post Office Box 2449 Madison, MS 39130-2449 1-800-844-2555 FAX (601) 856-8088 If you do not already have AdobeReader installed on your computer, Click Here to download. Plug-ins: Adobe Flash Player, Adobe Acrobat Reader, Windows Media Player. Superior Vision Services Attn: Claims Processing P.O. Our state online blanks and complete recommendations remove human-prone mistakes. It contains important information about your vision plan and your right to contest a claim decision or file a Grievance. State of Texas Vision | ERS 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. If you do not already have AdobeReader installed on your computer, Click Here to download. Windows OS: To zoom in press CTRL + PLUS SIGN (+). Customer service representatives are trained to respond to calls quickly, resolve problems promptly and exercise sensitivity. Thank you. Superior Vision. Learn More About Our Routine Vision Care Services How do I find a network provider? We use cookies to improve security, personalize the user experience, enhance our marketing activities (including cooperating with our marketing partners) and for other business use. The health care insurer shall provide any service or pay any claim determined in a final administrative decision to be covered and medically necessary for the case under review regardless of whether judicial review is sought. Mac OS: To zoom in press COMMAND + PLUS SIGN (+). Benefit Resources - The University of Southern Mississippi Check your benefits schedule to see how vision is covered Your Employer These networks offer members a discount on LASIK services when using an in-network QualSight provider. We collect Click-stream data, HTTP Cookies. SSL stands for Secure Sockets Layer, and it is the industry standard method for protecting web communications developed by Netscape Communications Corporation. Download Form OptumHealth Vision / United Healthcare. Box 967 u Rancho Cordova u California 95741 u 800-507-3800 u www.superiorvision.com . Many of the documents on this site are in PDF format. All pages have page titles and title tags written for easy comprehension of the page content. Type all required information in the required fillable fields. Box 967 Rancho Cordova, CA 95741 Fax: 916.852.2277. 200 East 18th Street Austin, TX 78701. Rehabilitation Act. 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. 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. Superior Vision: Plans, Benefits, and Costs | MyVision.org Main page content Document File(s) Superior Vison Claim Form. Title: Member Reimbursement Claim Form Author: Superior Vision Subject: Expense Reimbursement Created Date: Our HIPAA Compliancy Statement can be found here. You must have a printer configured. In order to obtain password, requestor must call 1 (800) 923-6766 (extension 2230). For a complete list of modifiers, refer to the Modifiers: Approved List section in this manual. Superior Vision Reimbursement Form Online - US Legal Forms You do not need to fill in all blanks. A cookie is an element of data that a website can send to your browser, which may then store it on your system. Author: Download the necessary form(s), print it out and fill in the required information. Ensuring members easy access to quality care with Superior Vision can help drive improvements in HEDIS/Stars scores. We reserve the right at any time and periodically to modify this site, temporarily or permanently, or any part thereof, with or without notice. Contact lenses Web pages are designed so that all information conveyed with color is also available without color. Moreover, you get full coverage for lenses, including polycarbonate. Superior Vision is a product offering from Versant Health, a company forged from the experience of two leading vision care plans. SVS-PRO10-001 v005 02/2014. Box 967 The user-friendly drag&drop graphical user interface allows you to add or relocate areas. Call Superior Vision Customer Service at (800) 507-3800, and someone who speaks your language can help you. Billing and Reimbursement for Vision Services . First, call Superior Vision Customer Service at (800) 507-3800 and get an authorization number / eligibility number. Superior Vision - Health Plans This includes uploading and downloading files. Most browsers have built-in accessibility features that our website supports. WELCOME PROVIDERS. Vision Wellness | Superior Vision Superior Vision's SmartAlert Wellness Program fosters communication between you, your eye care provider, and your primary care physician or . Birmingham, AL 35238-5018. Coverage includes routine eye exams and corrective eyewear, including frames, lenses, and contact lenses. Procedures to request FTP access for external groups. After completing the claim form, you may attach your receipt (s) OR print and mail copies of your claim form and receipt (s) to: Vision Service Plan. As this website contains links to other websites, Superior Vision makes no guarantee as to the content found on other sites. If the search engine finds more than 200 eye care professionals it only displays the first 200. We do not support any beta versions of Web browsers. PDF Member Reimbursement Claim Form - FramesDirect.com Contact Us | Find an Eye Care Professional | Disaster Relief. You can call our Customer Service Department at (800) 638-3120. Live customer service is available Monday through Friday from 8 a.m. to 9 p.m. and on Saturday from 11 a.m. to 4:30 p.m. Eastern time. Related. Pursuant to the requirements of this, Superior Vision shall select the provider physician or other health care professional who shall review the appeal and render the decision. Member Reimbursement Claim Form Use this form for reimbursement of services received from an out-of-network provider, or when . You may contact us by e-mail at privacy@superiorvision.com. We validate that all links and buttons can be accessed with a keyboard in a logical tab order and that all content is read by assistive technologies in the correct reading order. 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. The Superior Vision Plan is a vision care program designed to offer a high-level of vision care to you and your family. Gold Preferred Plan Services Frequency Email: Customer Service. 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. The Exclusive Collection. You may also contact the consumer assistance program at the New Jersey Department of Banking and Insurance. We will connect with you shortly. Superior Vision does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Download the data file or print your PDF version. The member shall mail a written appeal to Superior Vision within sixty (60) days after receipt of the adverse decision. If you do not already have a screen reader on your computer, there are free screen readers available online such as the open source NVDA screen reader. Grievance review will include the specific information considered and an explanation of the Direct... For all covered services Jersey Department of Banking and Insurance tags written easy. 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