Instructions

1. Review NVA contract summaries and fee schedules on www.nwvisionassociates.com.

2. Use this PPF to check the payers and networks you want to add through NVA. Attach additional paperwork where indicated.

3. Send NVA this PPF along with a current W-9. W-9 must be a 2018 version and dated within the last 30 days.

4. WAIT until you get confirmation of participation from a payer before you begin seeing patients! When in doubt, call the payer (not NVA) to verify your participation status.

Allow NVA at least 5 working days to process your information and add it to plan updates. NVA notifies payers on the 10th and 25th each month (Note: EyeMed only accepts updates once a month, we send these around the 25th).

Payer Networks and Requirements

YES! I want NVA to notify the payers I have checked to add me as participating through NVA. I understand that I am not active on a network until the payer confirms my effective date of participation.

Please provide OMAP/Medicaid Number

Email for NVA VR directory:

Web address for NVA VR directory:

EACH PAYER FOLLOWS THEIR OWN PROCESS FOR ADDING PROVIDERS TO NETWORKS. THIS CAN TAKE 7- 45 DAYS AFTER THEY RECEIVE NOTICE FROM NVA. ALWAYS CONTACT PAYERS TO VERIFY YOUR PARTICIPATION STATUS AND INCLUDED LOCATIONS BEFORE SEEING PATIENTS. PAYERS DO NOT VERIFY YOUR STATUS TO NVA.

The signature below confirms the choices on this PPF. Signer understands that NVA will transmit all practice locations in a doctor’s NVA membership to the payers and networks selected; each payer determines a doctor’s effective date of participation; and each doctor must meet all payer requirements.

Physician's (or designee's) Signature:

Date

Physician Name(s)*

Practice Name(s)*

Practice Tax ID (list all that apply)*

Practice Email*

Phone*

Phone

This field is for validation purposes and should be left unchanged.

Payer Participant Form

Payer Participant Form

Instructions

Payer Networks and Requirements

EACH PAYER FOLLOWS THEIR OWN PROCESS FOR ADDING PROVIDERS TO NETWORKS. THIS CAN TAKE 7- 45 DAYS AFTER THEY RECEIVE NOTICE FROM NVA. ALWAYS CONTACT PAYERS TO VERIFY YOUR PARTICIPATION STATUS AND INCLUDED LOCATIONS BEFORE SEEING PATIENTS. PAYERS DO NOT VERIFY YOUR STATUS TO NVA.