Legal

To enable us to maintain our strong quality assurance and improvement standards, Superior Vision has a formal grievance policy and procedure. This policy is for when members have questions or concerns about the quality of vision care that they receive, or have an issue with a claim. For a full copy of our policy, please click here to request it.

Some states require a specific grievance policy and procedure. Please click on your state below to view.

Quality care or servicer service

In the case that you are not pleased with the quality of care or level of service obtained through one of our participating eye care professionals, we encourage and request that you notify us – in writing – as soon as possible.

Resolving claim problems or concerns

If you have a problem or concern regarding claims, you should first call the Superior Vision Plan Customer Service toll free number. If you disagree with the decision or explanation given to you by the Customer Service Representative or if you have a complaint about any other issue regarding your insurance, you may request a grievance review.

To request a formal grievance review

The preferred option is to send your grievance in writing to:

Superior Vision Services, Inc.
P.O. Box 791
Latham, NY 12020

You may also fax it to us at (888) 343-3475 or email at CAG@versanthealth.com.

Make sure to include the following information:

  • Name of insured / subscriber
  • ID number of insured
  • Name of patient
  • Name of eye care professional / practice
  • Address of eye care professional (street, city, state)
  • Date of service
  • Description of grievance and issue:
    • Quality of care?
    • Level of service?
    • Claims dispute?
    • A concern or observation?

Make sure to include specific names of individuals and any steps you have already taken to remedy the issue or dispute (if applicable). A grievance may be submitted to us by or on behalf of a covered person within 180 days of the date of treatment, event, or circumstance giving rise to the grievance, such as the date of the claim denial.

Superior Vision Services
11101 White Rock, Suite #150
Rancho Cordova, CA 95670

You may contact us by e-mail at privacy@superiorvision.com.

You may call us at (800) 507-3800.

Data collection

We collect Click-stream data, HTTP Cookies. At the user’s option, we may also collect Search terms, Given Name (First Name), Family Name (Last Name), User’s Identity certificate, Telephone numbers, On-line address, and Unique identifiers. We collect this data for the purpose of site administration, completing the user’s current activity, and site customization. This data will be given to ourselves and our agents. We collect this information for the following reason:

Information gathered at this site is used for: Web traffic and error reporting, account identification and service listing, contact information for follow up communication and customer care, eye care professional search functionality. Information is not shared with organizations not an entity of Superior Vision Services, its Web delivery partner, software vendors, brokers or service eye care specialists.

Cookies

Cookies are a technology which can be used to provide you with tailored information from a website. A cookie is an element of data that a website can send to your browser, which may then store it on your system. You can set your browser to notify you when you receive a cookie, giving you the chance to decide whether to accept it.

Our site makes use of cookies. Cookies are used for the following purposes:

  • Site administration
  • Completing the user’s current activity
  • Site customization

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. We provide the following to ensure individuals with disabilities have access to our services.

Website accessibility

Superior Vision has adopted the following Priority 1 Checkpoints of the Web Content Accessibility Guidelines 1.0 (WCAG 1.0) (May 5 1999) published by the Web Accessibility Initiative of the World Wide Web Consortium: 1.1, 1.4, 2.1, 6.1, 1.2, 9.1, 5.1, 5.2, 12.1, 7.1, 11.4 as our website accessibility standard and are working to ensure that our website complies with that standard, as well as Section 508 of the U.S. Rehabilitation Act.

We test content for accessibility during production and are constantly working to improve our website accessibility. Some of our current accessibility features include:

  • Method to skip repetitive navigation links.
  • Alternative text for images and other non-text elements.
  • Structural markup to indicate headings and lists (semantics) to aid in page comprehension.
  • Form fields with associated labels and error messages to assist with completing the form.
  • Markup is used to associate data and header cells. Association of all data cells in a data table with their headers and only using table structures for tabular data and not for layout design. All pages have page titles and title tags written for easy comprehension of the page content.
  • JavaScript and style sheets to enhance the appearance and functionality of the site. If these technologies are not available, our page design helps ensure graceful degradation.
  • 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.
  • Pages are designed to avoid causing the screen to flicker with a frequency greater than 2 Hz and lower than 55 Hz.
  • When timed response is required, the user is alerted and given sufficient time to indicate more time is required.
  • Web pages are designed so that all information conveyed with color is also available without color.

Our website supports all the major browsers, including IE8 and above. It is best viewed with Java Script enabled.


PDF (Portable Document Format) files

Many of the documents on this site are in PDF format. Publications in PDF can be viewed and printed using the Adobe Acrobat Reader® or other PDF readers. We work to make our PDFs accessible for use with assistive technology such as screen readers like JAWS and NVDA. This includes “tagging” for alternate text in images, table headings in data tables, semantic structural elements like headings and lists and reading order. We also set the language and title attributes in the properties so assistive technologies know what language to use. If you encounter a PDF that you cannot read, please contact us.

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.

If you would like more information about PDF accessibility, visit the Adobe website accessibility section. For more help with Acrobat files generally and a link to download Acrobat Reader visit the site help page


Usability tips

Most browsers have built-in accessibility features that our website supports.

To zoom in or out on a web page:

  • Windows OS: To zoom in press CTRL + PLUS SIGN (+). To zoom out press CTRL + MINUS SIGN (-).
  • Mac OS: To zoom in press COMMAND + PLUS SIGN (+). To zoom out press COMMAND + MINUS SIGN (–).

To change foreground and background colors:

  • Internet Explorer: Select Tools > Internet Options > General dialog page, and the Colors button. Check the dialog boxes to set individual preferences.
  • Firefox PC: Select button labelled Firefox (orange) at top of screen > Options. In the dialog box, select Content > Fonts & Colors.
  • Firefox Mac: Select button labelled Firefox (orange) at top of screen > Preferences > Content> Color.
  • Chrome PC & Mac: Select the “hamburger” icon (for older PC version it is a wrench) at top of screen > Settings > Show Advanced Settings (for older PC versions Select Advanced Content) and scroll to Web Content.


Help us make this website more accessible

We are trying to make our website as accessible as possible for all of our visitors. Please contact us if you have any issues accessing information on this website. We welcome your feedback and suggestions.

For more insight about website accessibility visit the Web Accessibility Initiative website.

All information presented on the Superior Vision website is provided solely for general consumer understanding and education. This site and all content comprising the site, is for educational purposes only and is not a substitute for professional medical advice or vision health care. We strongly advise members to always seek the advice of a vision/eye care professional with any questions about vision and eye care or any medical condition. Members should not delay in contacting a vision/eye care professional based on information they have obtained from this site, or any site whose link may be found on the Superior Vision website. If you believe you have a vision problem or condition, contact a qualified vision care professional immediately.

As some content on this site is provided by other organizations and web content providers, Superior Vision cannot and does not guarantee the accuracy, timeliness and/or source of information from these organizations. Superior Vision makes no guarantee as to the content found on other sites. Users of this website use links to other websites at their own risk.

We reserve the right at any time and periodically to modify this site, temporarily or permanently, or any part thereof, with or without notice.

Each Virtual Private Servers resides in a protected sandbox with 24/7 monitoring.

FTP instructions

Procedures to request FTP access for external groups.

If you are a group that wants to participate in the file exchange program you will need to fill out online request form and submit it to the IS Department at Superior Vision Services for review.

Once the request is approved, a formal document outlining your account will be sent out via fax or email. Everything needed to begin using the account will be contained in this document, except for your password.

In order to obtain password, requestor must call 1 (800) 923-6766 (extension 2230).

All completed forms will be filed in the FTP access folder maintained in the IS Department.

File transfer center

This browser accessible interface can be used to manage your site. It has full administrative capabilities and will allow you to set preferences. Here you will be free to change your password to whatever you like and of course maintain file management. This includes uploading and downloading files.

Superior Vision Benefit Management, Inc., Superior Vision of New Jersey, Inc., Superior Vision Insurance Plan of Wisconsin, Inc., UVC Independent Practice Association, Inc., Superior Vision Services, Inc., and Block Vision of Texas, Inc. d/b/a Superior Vision of Texas and their affiliates (collectively, “Superior Vision”) comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Superior Vision does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Superior Vision:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact our Health Plan Member Services at (800) 243-1401.

If you believe that Superior Vision has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Compliance Officer, 939 Elkridge Landing Road, Suite 200, Linthicum, MD 21090, 800-243-1401 (TTY: 1-800-201-7165), or email to compliance@superiorvision.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Compliance Officer, is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Superior Vision, under the CA Language Assistance Program, utilizes Language Line Services to provide free language assistance services for our members who have limited proficiency in English. You may have an interpreter made available to you free of charge to facilitate your conversation with your eye care professional or Superior Vision. We can also provide member benefits materials to you in Spanish.

Call Superior Vision Customer Service at (800) 507-3800, and someone who speaks your language can help you. Contact Us

Superior Vision, bajo el Programa de Asistencia Lingüística (LAP, por sus siglas en inglés), provee el servicio gratuito de interpretación a nuestros miembros que prefieren contactarnos en español. De esta manera y totalmente libre de cargo tendrá a su disposición un intérprete que habla su propio idioma, mismo que facilitara su conversación con su proveedor de cuidado de ojos o con Superior Vision. También podemos proporcionarle material en español acerca de sus beneficios.

Llame al Centro del Servicio al Cliente al 1.800.507.3800, y alguien que habla su idioma lo ayudara. Tenemos intérpretes en español, chino, vietnamita, tagalo y coreano.

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.

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.

Superior Vision has provided partnership opportunities for diverse suppliers in the following areas, including, but not limited to:

  • Print and fulfillment services
  • Professional/Consulting services
  • Promotional products

Additionally our affiliate company, Davis Vision, Inc also promotes supplier diversity through a similar good faith effort to support and contract with diversity suppliers in the markets where we operate. Combined, our two companies have spent over $1.5MM with diverse suppliers in 2017.

Superior Vision and Davis Vision seek to continue our efforts to provide opportunities to diverse suppliers as we combine our sourcing focus in 2018.

All information presented on the Superior Vision website is provided solely for general consumer understanding and education. 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. This site, its services and content do not constitute the practice of any vision care, medical, or other professional health care advice, diagnosis or treatment. Access and use of this website is completely voluntary and is the sole risk of the user.

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. Users should not delay in contacting a vision/eye care professional based on information they have obtained from this site, or any site whose link may be found on the Superior Vision website. If you believe you have a vision problem or condition, contact a qualified vision care professional immediately.

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. As this website contains links to other websites, Superior Vision makes no guarantee as to the content found on other sites. Users of this website use links to other websites at their own risk.

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 Services is concerned about your security. To protect you we use SSL 3.0, [RC4 with 128 bit encryption (High); RSA with 1024 bit exchange]. SSL stands for Secure Sockets Layer, and it is the industry standard method for protecting web communications developed by Netscape Communications Corporation. The SSL security protocol provides data encryption, server authentication, and message integrity for your connection.

To protect your account data in the unlikely chance of a system compromise, the website does not maintain a live connection to the main benefits system. Periodic downloads of only essential data necessary to delivery quality web services are used to ensure account security.

We update our website data several times each month, changes in account information may not be reflected immediately, if you have a concern with an account update please contact security@superiorvision.com.

How do I search for an eye care professional?

Select ‘Find an eye care professional’ from the top of any page. Enter the information you wish to search on. You do not need to fill in all blanks. See below for search help. Click on the ‘Search’ button or hit ‘Enter’ to begin the search.

What if I don’t find an eye care professional?

You can enter a new search by hitting the ‘New Search’ image. If you didn’t find any eye care professionals it was probably because you made your search too ‘narrow’. Try eliminating some of the search information.

What if it reports that too many eye care professionals were found?

If the search engine finds more than 200 eye care professionals it only displays the first 200. Try to make your search more ‘narrow’ by adding other information to the search. You can enter a new search by hitting the ‘New Search’ image.

How can I print the search results?

Use your browser’s print option. If you have a PC running Windows, choose File then Print. You must have a printer configured. See below for printing problems.

Why is my account information not up-to-date?

For security reasons the data that is used to build the Web pages is not taken from Superior Vision Services ‘live’ database. As a result it may not always be 100% up-to-date. If there is every a question about accuracy, please contact us through the website or at (800) 507-3800.

At Superior Vision, our benefits management tools are made available over the internet through a Web browser. The Superior Vision website takes advantage of several advanced Internet and browser technologies to create the best possible user experience.

To optimize your experience on the Superior Vision website, your system must meet the following software requirements:

  • Operating System: Any version of Microsoft Windows family of operating systems
  • Browser: Netscape Navigator 4.7 +, Microsoft Internet Explorer 5.0 + or Mozilla Firefox 2.x +.
  • We do not support any beta versions of Web browsers.
  • Screen resolution: 800×600 or higher
  • JavaScript enabled
  • Cookies enabled
  • Plug-ins: Adobe Flash Player, Adobe Acrobat Reader, Windows Media Player

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Superior Vision is a product offering from Versant Health, a company forged from the experience of two leading vision care plans. To proceed with learning about available career opportunities within Versant Health, please click on the button below.

Grievance and appeal procedures for Arizona

Welcome to the Superior Vision Plan underwritten by National Guardian Life Insurance Company (NGLIC). NGLIC contracts with Superior Vision Services, Inc. to provide access to their network of vision care providers. The Superior Vision Plan is a vision care program designed to offer a high-level of vision care to you and your family. We do this through a broad-based provider network comprised primarily of board-certified ophthalmologists (MD) complemented by optometrists (OD), opticians, and optical companies who are responsible for delivering quality services.

Superior Vision Plan offers one of the largest networks of vision care providers. 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.

Please read this notice carefully. It contains important information about your vision plan and your right to contest a claim decision or file a Grievance.

Definitions

“Covered Person” means an eligible employee or his or her eligible dependents covered under the Superior Vision Plan. The term Covered Person includes a representative duly authorized in writing to submit a Grievance on behalf of the Covered Person.

“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:

  1. a. Placing the member’s health in serious jeopardy;
  2. b. Serious impairment to any of the member’s bodily functions; or
  3. c. Serious dysfunction of any of the member’s bodily organs or parts.

“Grievance” means a written complaint submitted by or on behalf of Covered Person regarding:

  1. a. The availability, delivery, or quality of vision care services;
  2. b. Claims payment, handling, or reimbursement for vision care services; or
  3. c. Any other matter pertaining to the contractual relationship between a Covered Person and the Insurer.

“Insurer” means the insurance carrier underwriting the Superior Vision Plan.

“Urgent” means non-life or limb threatening, or vision acuity is affected prior Vision Plan provides wellness benefits for routine eye examinations and eyewear in accordance with the terms and conditions of the Master Policy. It does not cover treatment of a medical or ophthalmologic condition. Contact your Medical Plan if you have questions concerning coverage for treatment of a medical or ophthalmologic condition.

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:

  1. a. For “Emergency Medical Conditions” situations, members are directed to contact their local EMC, or call 911.
  2. b. For “Urgent” medical conditions, members are instructed to contact their Medical Plan or Provider or local UCC.
  3. c. For immediate situations where a member may have lost or damaged his or her contact lenses or eyeglasses and the member is out-of town, a customer service representative may facilitate directing the member to a contracted provider in the area.
Resolving claim problems or concerns

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. Most problems or concerns can be handled with a single phone call. A customer service representative will work with you to help you understand your coverage or resolve your problem or concern as quickly as possible.

Customer service representatives are trained to respond to calls quickly, resolve problems promptly and exercise sensitivity.

When resolving a problem or concern, we will consider all aspects of the particular case, including the terms of your insurance certificate, the policy and procedures that support your insurance coverage, the provider’s input, and your understanding and expectations of your coverage. We will use every opportunity to be reasonable in find a solution that makes sense for all parties. We will follow our standard business practices guidelines when resolving your problem or concern.

Who to contact

If you disagree with the decision or explanation given to you by the customer service representative or if you have a complaint about any other issue regarding your insurance you may request a grievance review.

To request a formal grievance review you have three options.

  1. The preferred option is to send your Grievance in writing (company specific form is not required) to:
    “Grievances” Superior Vision Services, Inc.,
    Administrator for NGLIC
    11101 White Rock Road
    Rancho Cordova, CA 95670
  2. If you choose you may fax it to us at: 916-852-2290, or
  3. You may send your Grievance by email to CQI@superiorvision.com or through our secure website member portal.

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.

Requesting a grievance review

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.

Your request for a grievance review should include:

  • The name and identification number of the member asking for the review;
  • A description of the problem;
  • All relevant dates;
  • Names of health care providers or administrative staff involved; and
  • Details of the attempt that was made to resolve the problem.

A Grievance may be submitted to us by or on behalf of a Covered Person within one year of the date of treatment, event or circumstance giving rise to the Grievance, such as the date of the claim denial.

Written resolution of internal grievance review

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.

If deemed necessary and appropriate, your grievance may be forwarded to our CQI program.

As a participant in the plan you are entitled to certain rights and protections under the Employee Retirement Income Act of 1974 (ERISA). 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. If you have questions about your rights and responsibilities under ERISA you may contact the Benefits Security Administration, US Department of Labor, 200 Constitution Avenue NW, Washington DC 20210.

Written resolution of the grievance review will include the specific information considered and an explanation of the basis for the decision. We will provide you and the provider furnishing the vision care services, if applicable, a written decision within thirty (30) calendar days following the request for a review.

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.

Grievance review / appeal decision

Denial upheld – If we continue to agree that the covered services or claim for a covered service should have been denied, the complainant will receive a written notice of that decision.

Denial Reversed – If we agree that the covered services should have been provided, or that the claim should have been paid we will authorize the service or pay the claim.

Grievance records

We will maintain a record of each Grievance, including the response for each grievance review, for up to seven years.

As an Arizona member participant, any member who is denied a covered service or whose claim for a service is denied may pursue the applicable review process.

Formal appeal
  1. After any applicable consideration Superior Vision denies the member’s request for covered service, the member may appeal that adverse decision. The member shall mail a written appeal to Superior Vision within sixty (60) days after receipt of the adverse decision. In the event of a denial of a claim for a service that has already been provided, the member may request, either orally or in writing, an informal reconsideration by notifying Superior Vision within two (2) years after the receipt of the notice of denial.
  2. Superior Vision shall mail a written acknowledgement to the member and the member’s treating provider within five (5) business days after Superior Vision receives the formal appeal.
  3. The member or the member’s treating provider shall submit to Superior Vision with the written formal appeal, any material justification or documentation to support the member’s request for the service or claim for a service.
  4. If the member’s compliant is an issue of medical necessity under the coverage document and not whether the service is covered, a provider, physician, or other health care professional who is licensed pursuant to title 32 of the Arizona revised statutes, chapter 7,8,11,13,14,16,17,19 19.1, or 29 or an out of state provider physician or other health care professional who is licensed pursuant to title 32 of the revised Arizona statutes, chapter 7,8,11,13,14,16,17,19 19.1, or 29 or an out of state provider, physician or other health care professional who is licensed in another state and who is not licensed in Arizona and who typically manages the medical condition under appeal shall review the appeal and render a decision based on the utilization review plan adopted by Superior Vision. 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.
  5. Except as provided in section F. (below), Superior Vision has:
    1.With respect to adverse decisions relating to services that have not been provided, up to thirty (30) days after receipt of the written appeal to notify the member in writing of Superior Vision’s decision and the criteria used and the clinical reasons for that decision. 2.With respect to denials relating to claims that have already been provided, up to sixty (60) days after receipt of the written appeal to notify the member in writing of Superior Vision’s decision and the criteria used and the clinical reasons for that decision.
  6. At any time during the formal appeal process Superior Vision may request an external independent review process. If Superior Vision initiates the external independent review process, Superior Vision does not have to comply with section E. (above).
  7. 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.
  8. 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 Vision’s decision.
External independent review
  1. If Superior Vision denies the member’s request for a covered service or claim for a covered service at Formal Appeal level, the member may initiate an external independent review.
  2. Except as provided in section K. (below) within sixty (60) days after the member receives written notice by Superior Vision of the adverse decision, if the member decides to initiate an external independent review, the member shall mail to Superior Vision a written request for an external independent review, including any material justification or documentation to support the member’s request for the covered service or claim for a covered service.
  3. Except as provided in section K. (below), within five (5) business days after Superior Vision receives a request for an external independent review from the member pursuant to section B and G, or if Superior Vision initiates an external independent review, Superior Vision shall: 1.Mail a written acknowledgement to the director, member and the member’s provider and the health care insurer. 2.Forward to the director the request for review, the terms of the agreement in the member’s policy, evidence of coverage or a similar document and all medical records and supporting documentation used to render the decision pertaining to the member’s case, a summary description of the applicable issues including a statement of Superior Vision’s decision, the criteria used and clinical reasons for that decision, the relevant portions of Superior Vision’s review plan and the name and credentials of the licensed health care provider who reviewed the case.
  4. Except as provided in section K, within five (5) days after the director receives all of the information prescribed in section C, the director shall choose and independent review organization and forward to the organization all of the information required by section C.
  5. Except as provided in section C (above) for cases involving an issue of medical necessity under the coverage document, within twenty-one (21) days after the date of receiving a case for independent review from the director, the independent review organization shall evaluate and analyze the case and, based on all information required under section C (above) render a decision that is consistent with the utilization review plan on whether or not the service or claim for the service is medically necessary and send the decision to the director. 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 member’s treating provider. The decision by the independent review organization is a final administrative decision pursuant to title 41 of the Arizona revised statutes, chapter 6 article 10 and is the subject to judicial review pursuant to title 12, chapter 7, article 6, article 10 and is subject to judicial review pursuant to title 12, chapter 7, article 6. The health care insurer shall provide any service or pay any claim determined to be covered and medically necessary by the independent review organization for the case under review regardless of whether the judicial review is sought.
  6. Except as provided in section K of this section, for cases involving an issue of coverage, within fifteen (15) business days after receipt of all of the information prescribed in section C (above) from Superior Vision, the director shall determine if the service or claim is or is not covered and if the adverse decision conforms to Superior Vision’s utilization review plan and this article and shall mail a notice of determination to Superior Vision, the health insurer, the member and the member’s treating provider.
  7. If the director finds that the case involves a medical issue or is unable to determine issues of coverage, the director shall submit the member’s case to the external independent review organization in accordance with section E (above) or K (below).
  8. After a decision is made pursuant to sections E, F, G or K, the reconsideration, appeal and administrative processes are completed and the department’s role is ended, except:
    1. To transmit, when necessary, a record of the proceedings to superior court or to the office of administrative hearings. 2. To issue a final administrative decision pursuant to section 41-1092.08.I. Except as provided in section K (below) on written request by the independent review organization, the member or Superior Vision, the director may extend the twenty-one (21) day time period prescribed in section E (above) for up to an additional thirty (30) days if the requesting party demonstrates good cause for extension.
  9. 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.
  10. (20-2535 Expedited medical review; expedited appeal) – not applicable.
  11. Notwithstanding title 41 of the Arizona revised statutes, chapter 6, article 10 and section 12-908, if a party to a decision issued under this section seeks further administrative review, the department shall not be a party to the action unless the department files a motion to intervene in the action.
  12. The independent review organization, the director or the office of administrative hearings may not order the health care insurer to provide a service or to pay a claim for a benefit for a service that is excluded from coverage by the contract.
  13. 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. Any proceedings before the office of administrative proceedings that involve an expedited external independent review and that are subject to section K (above) shall be promptly instituted and completed.
Grievance records

We will maintain a record of each Grievance, including the response for each grievance review, for up to seven (7) years.

Replacement notice

You may obtain a replacement notice outlining this grievance and appeals process by contacting Superior Vision Services Customer Service Department at (800) 507-3800. 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.

Grievance policy New Jersey

Welcome to the Superior Vision Plan. Superior Vision Services, Inc. administers this plan to provide access to our network of vision care providers. The Superior Vision Plan is a vision care program designed to offer a high-level of vision care to you and your family. We do this through a broad-based provider network comprised primarily of board-certified ophthalmologists (MD), complemented by optometrists (OD), opticians, and optical companies who are responsible for delivering quality services.

Superior Vision Plan offers one of the largest networks of vision care providers. 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.

Please read this notice carefully. It contains important information about your vision plan and your right to contest a claim decision or file a Grievance.

Definitions

“Covered Person” means an eligible employee or his or her eligible dependents covered under the Superior Vision Plan. The term Covered Person includes a representative duly authorized in writing to submit a Grievance on behalf of the Covered Person.

“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:

  1. a.Placing the member’s health in serious jeopardy;
  2. b.Serious impairment to any of the member’s bodily functions; or
  3. c.Serious dysfunction of any of the member’s bodily organs or parts.

“Grievance” means a written complaint submitted by or on behalf of Covered Person regarding:

  1. a.The availability, delivery, or quality of vision care services;
  2. b.Claims payment, handling, or reimbursement for vision care services; or
  3. c.Any other matter pertaining to the contractual relationship between a Covered Person and the Insurer.

“Insurer” means the insurance carrier underwriting the Superior Vision Plan.

“Urgent” means non-life or limb threatening, or vision acuity is affected prior Vision Plan provides wellness benefits for routine eye examinations and eyewear in accordance with the terms and conditions of the Master Policy. It does not cover treatment of a medical or ophthalmologic condition. Contact your Medical Plan if you have questions concerning coverage for treatment of a medical or ophthalmologic condition.

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:

  1. a.For “Emergency Medical Conditions” situations, members are directed to contact their local EMC, or call 911.
  2. b.For “Urgent” medical conditions, members are instructed to contact their Medical Plan or Provider or local UCC.
  3. c.For immediate situations where a member may have lost or damaged his or her contact lenses or eyeglasses and the member is out-of town, a customer service representative may facilitate directing the member to a contracted provider in the area.
Resolving claim problems or concerns

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. Most problems or concerns can be handled with a single phone call. A customer service representative will work with you to help you understand your coverage or resolve your problem or concern as quickly as possible.

Customer service representatives are trained to respond to calls quickly, resolve problems promptly and exercise sensitivity. Response to your written grievance will not exceed 30-days from receipt of the complaint.

When resolving a problem or concern, we will consider all aspects of the particular case, including the terms of your insurance certificate, the policy and procedures that support your insurance coverage, the provider’s input, and your understanding and expectations of your coverage. We will use every opportunity to be reasonable in find a solution that makes sense for all parties. We will follow our standard business practices guidelines when resolving your problem or concern.

Who to contact

If you disagree with the decision or explanation given to you by the customer service representative or if you have a complaint about any other issue regarding your insurance you may request a grievance review.

To request a formal grievance review you have three options.

  1. The preferred option is to send your Grievance in writing (company specific form is not required) to: “Grievances”
    Superior Vision Services, Inc., (Administrator)
    11101 White Rock Road
    Rancho Cordova, CA 95670
  2. If you choose you may fax it to us at: 916-852-2290, or
  3. You may send your Grievance by email to CQI@superiorvision.com or through our secure website member portal.

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.

Requesting a grievance review

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.

Your request for a grievance review should include:

  • The name and identification number of the member asking for the review;
  • A description of the problem;
  • All relevant dates;
  • Names of health care providers or administrative staff involved; and
  • Details of the attempt that was made to resolve the problem.

A Grievance may be submitted to us by or on behalf of a Covered Person within one year of the date of treatment, event or circumstance giving rise to the Grievance, such as the date of the claim denial.

Written resolution of internal grievance review

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.

If deemed necessary and appropriate, your grievance may be forwarded to our CQI program.

As a participant in the plan you are entitled to certain rights and protections under the Employee Retirement Income Act of 1974 (ERISA). 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. If you have questions about your rights and responsibilities under ERISA you may contact the Benefits Security Administration, US Department of Labor, 200 Constitution Avenue NW, Washington DC 20210. You may also contact the consumer assistance program at the New Jersey Department of Banking and Insurance.

Written resolution of the grievance review will include the specific information considered and an explanation of the basis for the decision. We will provide you and the provider furnishing the vision care services, if applicable, a written decision within thirty (30) calendar days following the request for a review. If you are dissatisfied with the resolution reached through the SVS complaint system, you and/or any provider acting on behalf of you, may contest the decision by contacting the consumer assistance program at the New Jersey Department of Banking and Insurance at the following address and telephone number:

Department of Banking and Insurance?
Consumer Protection Services
Office of Managed Care
PO Box 329
Trenton, New Jersey 08625-0329
(888) 393-1062

Neither Superior Vision nor the Insurer shall discontinue coverage for or otherwise penalize any covered person or provider for exercising his or her right to file a complaint or grievance.

Grievance review / appeal decision

Denial upheld – If we continue to agree that the covered services or claim for a covered service should have been denied, the complainant will receive a written notice of that decision.

Denial reversed – If we agree that the covered services should have been provided, or that the claim should have been paid we will authorize the service or pay the claim.

Grievance records

We will maintain a record of each Grievance, including the response for each grievance review, for up to seven years.

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