Versant Health Provider Onboarding Roster

Versant Health Provider Onboarding Roster
Review your answers prior to submitting

Once you complete this form, you will be required to review your answers. You must select the submit button after reviewing the answers provided. Without selecting the submit button, we will not receive this completed form for processing.
Services*
Services

Wellness (Routine and Materials)Medical Surgical and Utilization Management

Office Information
Number of offices*
Input the number of service locations the practitioners will be linked to when credentialed onto the Davis Vision and/or Superior Vision Networks. Ensure you enter a record for each service location.
Adding new office(s) onto the network(s)?*

Yes. An Americans with Disabilities Act (ADA) Provider Attestation Form and Federal Disclosure of Ownership Forms for each new location is required. See below under Versant Health Forms.No
Adding new office(s) onto the network(s)?*
For additional offices, select the + button below
Office(s) Name(s)*
Office(s) currently on the Davis Vision or Superior Vision Network(s)?*
Office Address*
Office(s) Service Type*
Mobile/Telemedicine/Home Visit(s) Service Type(s) when applicable
Select Pediatric Age Group(s) when applicable
Office(s) Contact Information*
Office(s) Point of Contact(s)*
Office(s) Location NPIs and Tax Identification Numbers*
W-9 Form(s)*

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Office(s) Group Medicaid and/or Medicare IDs*
Medicaid and/or Medicare Plans

Individual Medicaid and Medicare ID(s) and Location Medicaid and Medicare ID(s) are required to service Medicaid and/or Medicare plans. If pending or N/A, the practitioner and/or location will not be able to service Medicaid and/or Medicare plans until our systems are updated.

To update a participating practitioner and/or locations' Medicaid and/or Medicare ID, visit the Provider Resource Center Forms Page to complete a Provider Change Form.

Valid Medicaid and/or a Medicare IDs are required for the practitioner to service Medicaid and/or Medicare plans.
Office(s) Affiliation with a Retailer*
Versant Health Exclusive Frame Collection

As an in-network provider¹, you may receive the Exclusive Collection which is inclusive of 222 frames or 48 Medicaid frames² to add to your existing selection. Showcased on a compact rotating fixture, a display of top-selling eyewear offered to members for low-to-no out-of-pocket cost. Can also be ordered to sell to your non-members at your own determined price.
¹Subject to change based on demographics.
2Superior Vision Providers
Versant Health Exclusive Frame Collection(s)*
Office(s) Versant Health Exclusive Frame Collection housing option*
Office(s) Shipping Address

Practitioner Information
Number of Practitioners*
Input the number of practitioners needing to be added or credentialed onto the Davis Vision and/or Superior Vision Networks. Ensure you enter a record for each practitioner at each office # (location).
For Additional Practitioners, select the + Button Below
Practitioner Information*
Practitioner Information*
Practitioner's will be added onto the Davis Vision or Superior Vision Networks?*
Practitioner Information*
Practitioner Information*
*New York Medicaid Providers: Provide copies of annual compliance certification(s) (required)

Required for New York Medicaid Providers Only
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Practitioner's annual compliance certification(s) are a part of the Annual Certification of Statement for Provider Billing Medicaid Form. This certification is required to be submitted to eMedNY on the anniversary date of the provider’s enrollment in Medicaid.

Form sample here: eMedNY ETIN CERT FORM
Medicaid and/or Medicare Plans

Individual Medicaid and Medicare ID(s) and Location Medicaid and Medicare ID(s) are required to service Medicaid and/or Medicare plans. If pending or N/A, the practitioner and/or location will not be able to service Medicaid and/or Medicare plans until our systems are updated.

To update a participating practitioner and/or locations' Medicaid and/or Medicare ID, visit the Provider Resource Center Forms Page to complete a Provider Change Form.

Valid Medicaid and/or a Medicare IDs are required for the practitioner to service Medicaid and/or Medicare plans.

Versant Health Forms
Versant Health Americans with Disabilities Act (ADA) Provider Attestation Forms

For multiple service locations, one is required per location
Versant Health Americans with Disabilities Act (ADA) Provider Attestation Form (right click - Save As)
Versant Health Americans with Disabilities Act (ADA) Provider Attestation Forms Forms Upload*

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Versant Health Disclosure of Ownership Forms

If a practitioner has ownership/interest in the entity, a form is required forthat specific practitioner, along with one for the entity
Federal Disclosure of Ownership Forms (right click - Save As)
Federal Disclosure of Ownership Forms Upload*

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Are any of these locations a Federally Qualified Health Center? *
Attach Encounter Rate Approval Notice

For multiple office location(s), ensure an approval notice is included for all locations. Include if encounter rates are inclusive of vision, medical and/or materials.
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Are any of these locations an Indian Health Service or Tribal Health Service?*
Are any of these locations in the New Jersey Maps Program? *

Confirmation
Contract for Plan Types*
Plan Types*

All Health PlansMedicareMedicaidInsurance through Employer
Retailer Code(s)
Nomination Code
Versant Health Network Development Representative
If you worked with a Network Development Representative, please indicate who from the dropdown menu.
Supplemental Credentialing Documentation

Inclusive of Superior Vision Provider Fee Schedule and/or Participating Provider Agreement(s). If not applicable, do not attach documentation.
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Signature*

Clear
Attestation: I understand and acknowledge that neither the submission of a completed Versant Health, Provider Application nor the execution of a Versant Health Participating Provider Agreement constitutes acceptance as a Versant Health Participating Provider. Acceptance as a Versant Health Participating Provider is contingent on the acceptance by Versant Health of an applicant’s completed Application, and onthe execution by the applicant of a Versant Health Participating Provider Agreement, and on the receipt by the applicant of the forms, manual and samples requiredfor participation. Versant Health reserves the absolute right to determine which applicant is acceptable for participation and in which groups an applicant will participate. Versant Health, Provider Application submission signifies your consent to receive important updates about your application progress via email.
Signer Name*

First NameLast Name
Surgical Privileges

Complete a Versant Health Surgical Privileges Intake Form for practitioners with surgical privileges.
If applicable, a Versant Health Surgical Privileges Intake for each practitioner and service location will be required.
Review your answers prior to submitting

After completing this form, you will be required to review your answers. You must select the submit button after reviewing the answers provided. Without selecting the submit button, we will not receive this completed form for processing.

*Versant Health Use Only
Exclusive Collection(s)
Contract Type

GroupIndividual
Plans to be mapped
Lab Usage
REIM
Fee Schedule Type
Should be Empty:

Versant Health Provider Onboarding Roster

Review your answers prior to submitting

For additional offices, select the + button below

For Additional Practitioners, select the + Button Below

Versant Health Americans with Disabilities Act (ADA) Provider Attestation Forms

Versant Health Disclosure of Ownership Forms

Review your answers prior to submitting