Optometry Credentialing 101 – Getting Started as a New Graduate

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Optometry Credentialing 101 - Getting Started As a n

Understanding what optometry credentialing means is the first thing you need to do as you transition from student to practicing optometrist.

After you graduate from optometry school, the next logical step would be to begin working. If you plan on examining patients who wish to use their vision and medical insurance, you must be a “provider” with that insurance company. In order to become a “provider,” you must be credentialed with that particular insurance. Unfortunately, most insurances, both medical and vision, have their own credentialing processes and procedures. In short, optometry credentialing can be a long and arduous process, ripe with confusion and of course frustration.

This article will summarize the nuts and bolts of optometry credentialing, and provide the foundations for getting started. The credentialing process typically takes place after you have applied for and received your state license.

Read this article for an in-depth guide on how to get your license in all 50 states.

So what do you do after you receive your license? Here we will cover the process step-by-step.

1. Getting Your NPI Number

A National Provider Identifier (NPI) is a unique 10-digit identification number issued to healthcare providers in the US by the Centers for Medicare and Medicaid Services (CMS). You have to have an individual NPI for any insurance. You can apply for it before you have a job and use your home address. After you obtain a job, you can change the address associated with your NPI but are not required to.

2. Establish Your Tax ID

A Taxpayer Identification Number (TIN) is an identifying number used for tax purposes in the United States. It’s also know as a Tax Identification Number or a Federal Taxpayer Identification Number. It is not your Social Security number. If you are an individual that is not a corporation or a group NPI, you can use your Social Security number for insurances. As a rule of thumb, a Tax ID goes with a group and your Social Security number goes with an individual.

3. Apply for a Group NPI # (if necessary, ie: you incorporate, set up a LLC etc.)

If you are a group, a group NPI is a very good thing. If you use a Tax ID, it is usually a necessity. If you are an individual, you can use your individual NPI. You can always add a group NPI. It is a very simple task.

Read more on the nuts and bolts of getting credentialed.

Some ODs will begin their career working as an employee for a practice or corporation who might handle the credentialing process for them, while others might begin working as an independent contractor at various practice locations. In that case, you might be responsible for handling the credentialing process on your own, as well as the billing and coding (more on that topic later).

If you are responsible for handling the credentialing process on your own, you’ll need to continue with the following steps!

4. Register for CAQH.

CAQH was formerly known as the Universal Provider Datasource. Almost all insurances except Medicare and Medicaid require that you have CAQH and that it is up to date. It is a resource of all of a provider’s information in one place and it eliminates duplicate paperwork. To complete CAQH, a provider would need all of their education information, their work history, a few references (varies by state). The documents that are sometimes needed to be submitted (also varies by state) their professional license, DEA certificate, Certificate of Insurance, and resumes.

You can utilize this guide from more information on registering with CAQH.

5. Decide on what vision insurances and medical panels to participate in.

Communicate with your peers for this. Go to local society meetings and find out what others in your area are credentialed for. Call the large employers in your area to see what they have available for their employee health insurances. Check out the websites of other doctors in your area to gather some insight and information on what insurances they are taking.

Here’s a list of various insurances with guides on how to get credentialed with them.

6. Apply to be a provider for Medicare.

Typically the best place to start is here. You cannot proceed with optometry credentialing with several of the medical insurances until your Medicare is approved or at least processing (including Medicaid in some states). The average time it takes to process varies. I have been able to get some providers credentialed in about 2 weeks, and others it has taken a few months. The average waiting period is 60 to 90 days.

8. Begin the application process.

Most insurances have credentialing information on their websites or at least a contact phone number. If a new doctor is going to work for a group, usually someone there can tell them what they need to be credentialed for. I generally recommend you begin applying with medical insurances; however, it varies depending on what kind of environment and patients you will be working with.

Credentialing can be a time-consuming process and is often best performed by someone with experience! If you need assistance, feel free to contact Kenny Meyer at  Kmeyer@claimdoctor.net and he can help you credential for both routine and medical plans.

About Eric Botts O.D.

Eric Botts O.D.
Eric K. Botts has a Doctorate of Optometry from Southern College of Optometry, is a Third Party Trustee for Illinois Optometric Association, the President of the Energeyes Association, the Founder & Doctor of InnovativEyes Clinic, and the Founder & CEO of OBC Insurance Billing and Credentialing Specialists. Dr. Botts is a very passionate and engaging speaker with decades of real-world experience. He has hosted well over 250 Continuing Education Courses to 1,000s of fellow ODs! Besides having distinguished credentials Dr. Botts is a family man who has 3 daughters with his wife Lori, and they reside in the Midwest town of Macomb, IL.

One comment

  1. Ardis Okeke

    It is interesting to read your blog post and I am going to share it with my friends.republic

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