becoming a
medi-cal provider
Medi-Cal, California’s Medicaid program, is a public health insurance program financed equally by the state and federal government which provides needed health care services for low-income individuals including adults, families with children, seniors, persons with disabilities, foster care, pregnant women, and those with specific diseases.
Currently, Medi-Cal covers routine eye examinations and eyeglasses every two years. It also covers virtual and in-person office visits to treat medical eye conditions. Contact lens testing may be covered if the use of eyeglasses is not possible due to eye disease or condition (i.e., missing an ear). Coverage includes low vision services for those with vision impairment that is not correctable by standard glasses, contact lenses, medicine or surgery that interferes with a person’s ability to perform everyday activities (i.e., age-related macular degeneration). Medi-Cal also covers artificial eye services and materials for those individuals that have lost an eye or eyes to disease or injury.
Medi-Cal beneficiaries are enrolled either in the fee-for-service (FFS) program or with a managed care plan. In order to provide services to FFS Medi-Cal beneficiaries, you must be enrolled as a participating provider. For information regarding provider enrollment, please refer to the statutes, regulations and provider bulletins section and the application site at http://files.medi-cal.ca.gov/pubsdoco/prov_enroll.asp. Applicants are encouraged to review the forms and enrollment regulations as they contain application criteria terminology, processing timelines and the requirements for participation in the Medi-Cal program. Doctors of optometry are required to provide their NPI on their enrollment applications (see “Getting Your NPI”).
Prospective Medi-Cal providers must apply for and be enrolled in the Medi-Cal program and agree to conditions of participation before claim submission or payment can be made for services furnished to Medi-Cal recipients. Prior to approval of the application, an optometrist’s decision to see Medi-Cal patients is at his/her own personal risk for payment.
To provide services for beneficiaries on Medi-Cal Managed Care plans, in addition to enrolling with Medi-Cal, you will also need to submit an application to be on the panel of each plan in your area (see "Billing for Medical Eye Services").
Provider Application and Validation for Enrollment (PAVE) web-based application is designed to simplify and accelerate the MediCal enrollment processes. ODs can utilize the portal to complete and submit applications, report changes to existing enrollments, and respond to state Provider Enrollment Division (PED)-initiated requests or revalidation. PAVE features secure login, document uploading, electronic signature, application progress tracking, social collaboration and more.
The PAVE portal can be accessed at https://pave.dhcs.ca.gov/
Application instructions for optometrists can be found on the Provider Enrollment page on the Medi-Cal website at: https://www.dhcs.ca.gov/provgovpart/Pages/OptometristApplicationPackage.aspx
Instructions and FAQs on using PAVE: https://www.dhcs.ca.gov/provgovpart/Pages/PAVE.aspx
For questions on enrollment, contact the Provider Enrollment Division of the state Department of Health Care Services at (916) 323-1945, ext. 454, or by e-mail at PEDCorr@dhcs.ca.gov.
IMPORTANT! The processing of an application can take several weeks. After an application has been approved, you will receive a welcome letter and package which contains billing information. Usually within 2-3 weeks after receiving the welcome letter and package, a separate notification with your Provider Identification Number (PIN) will be mailed to you. Once you receive your PIN, you can begin verifying eligibility of your Medi-Cal patients and the billing process.
Provider Application Types
Sole proprietors: To set up as a sole proprietor, complete and provide necessary documentation as requested on each of the following forms:
Medi-Cal Provider Application — Form DHCS 6204
Medi-Cal Disclosure Statement — Form DHCS 6207
Medi-Cal Provider Agreement — Form DHCS 6208
2. Group providers: If you are a group provider, defined as two or more rendering providers doing business together under a group provider number, you will need to apply as a group provider. In addition to the group provider application, a rendering provider application must be submitted for each individual provider not enrolled in Medi-Cal who is rendering services for the group (see “Rendering Provider,” below). To set up as a group provider, complete and provide necessary documentation as requested on the Medi-Cal Provider Group Application — Form DHS 6203.
3. Rendering provider: If you are in an employed setting or if you are an independent contractor, your employer must be enrolled with Medi-Cal as a group provider and you must enroll as a rendering provider for each location at which you practice under either of these capacities. To become a rendering provider, complete and provide necessary documentation as requested on the following two required forms: 1) Medi-Cal Rendering Provider Application/Disclosure Statement/Agreement for Physician/Allied/Dental Providers — Form DHCS 6216 and 2) Form DHCS 4029.