Payer Participant Form Payer Participant Form "*" indicates required fields 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 RequirementsYES! 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.EYEMED VISION CARE | www.eyemedvisioncare.com Yes Required plans only (Access, Retinal Imaging, Diabetic Management). “Required” plans do not include Aetna routine, Aetna medical, Select, Insight, and Advantage networks. To participate in these you must submit an Eyemed “Optional Networks Form” to NVA which is found on NVA’s website.INTEGRATED HEALTH PLAN (IHP) PPO | www.ihplan.com Yes PACIFICSOURCE COMMERCIAL AND COORDINATED CARE | www.pacificsource.com Yes The Coordinated Care network is used for plans offered under the Affordable Care Act.PACIFICSOURCE MEDICARE | www.pacificsource.com Yes PacificSource must have verification of your Medicare number and effective date. **You may be required to supply your CMS letter if not able to be verified online.PACIFICSOURCE COMMUNITY SOLUTIONS (Medicaid) | www.pacificsource.com Yes This Medicaid contract is available for optometrists & ophthalmologists who practice in Oregon.Please provide OMAP/Medicaid Number PROVIDENCE HEALTH PLANS (PHP) EXCLUSIVE PROVIDER OPTION (EPO) | www.php.org Yes This network is for ODs only. It is used by Providence for most of it’s “commercial” plans.PROVIDENCE HEALTH PLANS (PHP) MEDICARE ADVANTAGE | www.php.org Yes This network is for ODs only. Includes Providence Medicare Prime effective 1/1/20. You must practice in a participating county.HiddenPROVIDENCE HEALTH PLANS (PHP) PREFERRED PROVIDER ORGANIZATION (PPO) | www.php.org Yes This network is for ODs only. PHP charges a fee to join for doctors practicing in Clackamas, Clark, Multnomah, and Washington counties. PHP will bill you annually.PROVIDENCE HEALTH PLANS (PHP) PROVCONNECT | www.php.org Yes This network is for ODs only. This is a Portland-area network for some Affordable Care Act plans. Providers must also participate in the EPO and must practice in Clackamas, Multnomah, or Washington county.PROVIDENCE HEALTH PLANS (PHP) PROVIDENCE-INTEL CONNECTED CARE | www.php.org Yes This network is for ODs only. This is a Portland-area network for Intel enrollees. Services must be authorized by a patient’s primary care physician or group. Providers must also participate in the EPO and must practice in Clackamas, Multnomah, or Washington county.PROVIDENCE HEALTH & SERVICES (PHS) OREGON CAREGIVER NETWORK | www.php.org Yes This network is for ODs only. This is a Portland-area network for Providence Caregivers (Employees) and their families. Providers must also participate in the EPO and must practice in Clackamas, Multnomah, or Washington county.PROVIDENCE HEALTH PLANS (PHP) OHP (Medicaid) | www.php.org Yes This network is for ODs only. This is a Portland-area network for Oregon Medicaid enrollees. Services must be authorized by a patient’s primary care physician or group. Doctors must practice in Clackamas, Multnomah, or Washington countyPlease provide OMAP/Medicaid Number PROVIDENCE HEALTH PLANS (PHP) YCCO OHP (Medicaid) | www.php.org Yes This network is for ODs only. This network is for Yamhill County CCO for Oregon Medicaid enrollees. Services must be authorized by a patient’s primary care physician or group. Doctors must practice in Yamhill, Marion, Polk, Clackamas, Multnomah and Washington County.Please provide OMAP/Medicaid Number SPECTERA | www.spectera.com Yes Includes Spectera and UnitedHealthcare Vision plans. All new clinic locations and new providers must complete the Spectera provider application. Three Rivers Provider Network (TRPN) PPO | www.trpnppo.com Yes TRPN requires all doctors billing under the same tax id (TIN) to participate. Find instructions about applying through NVA in the “NVA Contracts” section of the NVA web site. COMPLETE OPT-IN FORM FOUND ON WEBSITE AND SEND TO NVA WITH PPF.NVA Vision Rewards (NVA VR) | www.nwvisionrewards.com Yes You must list an email or web address for the NVA Vision Rewards directory:Email for NVA VR directory: Web address for NVA VR directory: First Health/Coventry Health Care (FH) PPO | www.firsthealth.com Yes Find instructions and a checklist for applying through NVA in the “NVA Contracts” section of the NVA web site. IF YOU APPLY, BE SURE TO SEND NVA YOUR “OPT IN” FORM SO WE KNOW YOU WANT TO PARTICIPATE THROUGH NVA!MultiPlan PPO | www.Multiplan.com Yes This contract includes participation in Beech Street PPO. Find instructions and a checklist for applying through NVA in the “NVA Contracts” section of the NVA web site. BE SURE TO SEND NVA YOUR “OPT IN” FORM SO WE KNOW YOU WANT TO PARTICIPATE THROUGH NVA!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: Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Physician Name(s)* Practice Name(s)* Practice Tax ID (list all that apply)* Practice Email* Person Completing Form* First Last Phone*PhoneThis field is for validation purposes and should be left unchanged.