Becoming credentialed as an optometrist with Medicare can be difficult. I would say it was one of the most difficult insurance carriers I joined. If you get it right the first time, you are in the clear with no worries. Mess up just once and you immediately delay the process by 3 months and lots of headaches!
- Credentialing with Medicare takes about 60 - 120 days from the time you submit your application
- You can do it online or on paper. The online version uses the PECOS system and the paper version requires forms CMS-855I form
- The people at Medicare phone support are actually the most helpful and knowledgeable of any insurance company I have dealt with
- You will need your state license, your NPI number and a good idea of your short term employment situation
The guide below is meant to be for optometrists who are considered "Employees" and not "Independent Contractors". The 2 are similar, and this guide will help you regardless of which type of provider you are. Also, this guide is for people using the PECOS online system, not the paper application. If you are an independent contractor, you should follow this guide on how to become a medicare provider.
Read before proceeding
This is my personal experience with the Medicare application process. I am in no way, giving you instructions for how YOU should apply. I am simply showing you the exact way that I went about it.
You need to understand that if you mess up the application process, it can really hurt your practice because you will not be able to see Medicare patients. Not having access to those patients can financially hurt your practice in more ways than one . . . I am not responsible if that happens to you.
If you are not prepared to claim responsibility for yourself then DO NOT use this article to help you. In all honesty, I know that this article will be helpful for you. It will speed up the process and help you nail it first try. It took me over 1 year to get on Medicare because of the mistakes I made, so I highly recommend using this article to avoid those same mistakes.
There is no guarantee the article is error free. CovalentCareers, its sponsors, advertisers, staff and writers make no representation, warranty, or guarantee that this article and its contents are error-free and will bear no responsibility or liability for the results or consequences of the information contained within. - Matt Geller O.D.
Step 1: Read about the process
You need to understand what you are getting into, and this is the Medicare website. Use this link to learn what it is you are about to do!
Step 2: Login to PECOS online system
Step 3: My Enrollments
Click My Enrollments button to get started.
Step 4: Identify Yourself
If this is your first application process, you might not see this. In some cases, you may have to click who it is that you are credentialing for.
Step 5: Ordering and Referring
The Affordable Care Act requires physicians or other eligible Non-Physician Practitioners (NPPs) to enroll in the Medicare Program to order/refer items or services for Medicare beneficiaries. This includes those physicians and other eligible NPPs who do not and will not send claims to a Medicare Administrative Contractor (MAC) for the services they furnish. Basically, you want to check "NO" here. You are becoming a Medicare Provider to do more than "Order and Refer", but to see patients. Checking "NO" will still let you order/refer, but you aren't doing this "SOLELY" to order/refer.
Step 6: Applicant Description
Are you one of the following...
- Sole Owner
- Self-Employed / Sole Proprietor / 1099 - if so, read this article
- Group member only
- Group member and self employed
- Disregarded entity
I chose group member because I am an employee at a private practice. We send all Medicare claims to the group and the Tax ID on the group, therefore I do not get paid directly from Medicare. The difference between Self Employed and Group Member / Self Employed is where the Medicare claims reimbursements go. In the former they go directly to you, the latter they go to the Tax ID of the practice. Discuss with your employer which method they prefer.
Step 7: Primary Medicare Services
Simply select "optometry". Since Part A of Medicare is associated with hospital services, this would make most optometrists Part B physicians.
Step 8: Topic Summary
Accept Assignment = You agree to accept the Medicare reimbursement rates and adhere to their rules. Read the CMS-460 agreement to fully understand your legal compliance with this.
Step 9: Fill out Medicare Participating Physician Agreement
I have heard 2 different stories about this.
- Fill out the agreement and scan it / send it in with your PECOS application
- Ignore the agreement - PECOS online is enough to validate the agreement
I am honestly not sure which is right. I personally filled it out and attached it. Your best bet is to call Medicare and ask since they are extremely helpful on the phone.
Step 10: Special Payments
When Medicare sends remittance notices and EOB's to you, where do you want them to go?
Step 11: Special Payments Details
In my case, I want my remittance notices to go to my employer's private practice. Therefore, I filled out the details for Eric M. White and Matthew D. Geller Optometry Practice.
Step 12: Special Payments Details
Fill out the contact information.
Step 13: Special Payments Details
The Medicare ID is also called your Medicare PTAN number. You want to put the PTAN of the GROUP, not the senior doctor. Every Medicare provider gets a PTAN, and the group also gets a PTAN. Put the Group PTAN here so that you are linked to the group.
Step 14: CLIA
Does your practice do laboratory testing and is it CLIA certified? If so, put your CLIA number here. My practice does not do this yet.
Step 15: Radiology
Does your practice do radiological testing and is it certified? If so, put your certification number here. My practice does not do this.
Step 16: Type of practice
What is your practice setting? Mine is a private practice, which is what I selected.
Step 17: Rendering Services at a Patient's Home
Do you do house calls for patients and often go to people's houses to do eye exams? If so, you need to enter that here. I do not, so no information was added. If you do, try to follow the prompts to the best of your ability.
Step 18: Reassignment of Benefits
A reassignment is when an individual assigns his/her benefits and payment to a group, individual, or organization already with Medicare. Because I am joining an existing group on Medicare, I chose this.
Step 19: Reassignment of Benefits Details
Note: Regarding “Reassigning Benefits” - if you were an independent contractor you WOULD NOT reassign benefits. This is because independent contractors receive reimbursements directly and not under the practice or a billing group/person. This is ONLY if you are a true independent contractor and not providing payments to the group Tax ID (see step 6 above).
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A message from the author - this is my personal experience with the Medicare application process. I am in no way, giving you instructions for how YOU should apply. I am simply showing you the exact way that I went about it.
You need to understand that if you mess up the application process, it can really hurt your practice because you will not be able to see Medicare patients. Not having access to those patients can financially hurt your practice in more ways than one.... I am not responsible if that happens to you.
If you are not prepared to claim responsibility for yourself then DO NOT use this article to help you. In all honesty, I know that this article will be helpful for you. It will speed up the process and help you nail it first try. It took me over 1 year to get on Medicare because of the mistakes I made, so I highly recommend using this article to avoid those same mistakes.
There is no guarantee the article is error free. NewGradOptometry.com, its sponsors, advertisers, staff and writers make no representation, warranty, or guarantee that this article and its contents are error-free and will bear no responsibility or liability for the results or consequences of the information contained within. - Matt Geller O.D.
Step-by-step credentialing guides
The credentialing process for different insurance plans varies quite a bit. Some plans are relatively simple and others require much more work. The below guides walk you through the process for the most common vision and medical insurance plans.
- 41 Step Guide to Become a Medicare Provider w/ Screenshots
- How Optometrists join Medicare as an Independent Contractor 1099
- The Complete Medicare Resource List
- How to Become an AETNA Provider
- How to Become an AlwaysCare Provider
- How to Become a Blue Shield of California Provider
- How to Become a Davis Vision Provider
- How to Become an EyeBenefits Provider
- How to Become an Eyemed Provider
- How to Become an EyeQuest Provider
- How to Become a FEDVIP Provider
- How to Become a Humana Vision Provider
- How to Become a Humana Medical Provider
- How to Become a Spectera Provider
- How to Become a United Health Care Provider
- How to Become a Vision Plan of America Provider
- How to Become a Vision Benefits of America Provider
- How to Become a VSP Provider
