DAVIS VISION Federally Qualified Health Center (FQHC) – Vision Billing Guide

Provider Enrollment/Credentialing

Contracting

To enroll as a network provider with Davis Vision, please visit https://davisvision.com/eye-care-professionals/join/ to send us a request to join the network. A Network Development Specialist will contact in fifteen (15) business days to discuss the provider enrollment process, which includes the Participating Provider Agreement, Provider Add Form, Fee Schedule(s), and the Credentialing Process. The entire provider enrollment process may take up to ninety (90) days. Questions regarding any of the Provider Enrollment process should be directed to the Network Development Specialist.

Credentialing

Credentialing by Davis Vision is coordinated by our Credentialing Team and Primary Source Verifications (PSV) are performed by our CVO, Gemini Diversified Services (Gemini).

The credentialing process starts by an Eye Care Professional’s CAQH Application being attested and all documentation be current and present in CAQH. Once Davis Vision deems a CAQH application complete, the provider will be issued an Application Completion Notification Letter, with the application completion date. The application complete date will be entered into the Davis Vision database and claims system as the date the provider is able to provide treatment and submit claims for service to Davis Vision. The provider’s application will then be sent to Gemini for PSV and once Gemini completes the provider’s initial credentialing file, Davis Vision will present the provider to the Davis Vision Credentialing Committee for approval.

If the provider’s application is incomplete, Davis Vision will make three (3) outreach attempts, within thirty (30) days for the provider to update their CAQH application. Documentation should not be sent to Davis Vision. The provider’s application status will remain “pending” until the application is deemed completed. If missing information is not updated in CAQH within the 30-day time period, Davis Vision will reject the application and the provider’s application will be closed.

If the Vision Provider has sanctions on their licenses, certificates or professional liability cases, the provider cannot treat Davis Vision Members until the Credentialing Committee reviews and approves the application for participation. By definition, presence of any of these items deems a provider’s application incomplete.

Claim Submissions

Claim Filing Deadlines

Davis Vision must receive all claims within 180 calendar days from the initial date when services were rendered. If claims are not received within 180 calendar days from the initial date of service, claims will be denied for untimely filing.

Procedures for Claim Submission

Davis Vision accepts claims submitted in any of the following formats:

  • Paper Claims
  • EDI
  • Versant Health Provider Web Portal

National Practitioner Identifier (NPI)

Davis Vision requires all practitioners use their NPI numbers for all claim submissions. To ensure our systems properly identify you as an individual, group or facility, Davis Vision requires you register the NPI with your taxonomy and tax identification numbers. Another requirement that will affect both timeliness and payment is the use of name differential on your W-9.

Davis Vision continues to accept the use of your provider identification numbers (legacy ID). The continued use of the legacy ID is recommended, as the claims processing system uses this number for adjudication and payment activities. Please make sure your name matches the name used on your W-9.

Claim Appeals

To file a claim appeal, a vision health care professional must complete and submit a “Health Care Provider Application to Appeal a Claim Determination” form to Davis Vision. These forms are available on the DOBI website at www.state.nj.us/dobi.

Appeal requests may be submitted to:
Davis Vision
Complaints and Appeals Department
PO Box 791
Latham, NY 12110
Fax: 888-778-1008
Email: providerca@versanthealth.com

IMPORTANT – Supporting documentation, e.g., proof of timely filing, may be submitted. Please follow all appropriate procedures as defined in the “Health Care Provider Application to Appeal a Claim Determination” before submitting an appeal to Davis Vision.

Upon review of the appeal, a decision will be rendered within 30 business days of the date of Davis Vision’s receipt of the claim appeal request. There is only one level of appeal with Davis Vision.

Benefit Limitation - Davis Vision may limit the quantity of certain services eligible for coverage per year. A claim denied for exceeding the benefit limit indicates that Davis has already paid up to the quantity of services eligible for coverage per year for the enrollee. If the service was not previously provided by the billing FQHC, the claim will be paid. However, if the service was previously provided by the FQHC, the claim will be denied