provider Panels

Identify the major plans in your geographic area. If the majority of the population in your practice location has a certain plan, it would make sense to become a provider. On the other hand, if there are virtually no patients covered by this plan in your area, question whether it would be worth your while to become a provider for that plan.

All panels try to make their reimbursement schedules appear as lucrative as possible. As a provider, educate yourself about:

• The reimbursement amounts for the examination and materials

• Costs for which you will be responsible

• Costs for which the panel will be responsible

Remember, each plan is organized differently with its own procedures and claims processes. Some plans are definitely easier to work with than others. However, you may not find this out until after you become a member. Read application instructions thoroughly, and check additional and specific requirements for each plan to which you are applying. Provider applications often require the following types of documentation:

• Proof of current professional liability certificate of insurance (see “Personal & Professional Insurance")

• Professional license (see “Licensure”)

• DEA certificate (see “DEA Numbers and Optometry”)

Credentialing is the administrative process for validating the qualifications of licensed professionals and assessing their background and legitimacy. In order to become a provider of vision and health plans you must be credentialed by each health organization. You will have to become credentialed separately by each plan. Once you are a provider of one health plan you may want to consider registering with the Universal Provider DataSource (UPD) (see “Resources,” below).

The UPD seeks to make the provider credentialing process more efficient for providers as well as health care organizations. Developed by the Council for Affordable Quality Healthcare (CAQH), a not-for-profit alliance of health plans, the UPD allows registered physicians and other health professionals to enter their credentialing information free-of-charge into a single, uniform online application that meets the credentialing needs of participating health plans, hospitals and other health care organizations. The provider data-collection service is not mandatory and exists to streamline the initial application and re-credentialing processes. To begin the UPD registration process log on to https://www.caqh.org/solutions/caqh-proview.

Under the federal Affordable Care Act (ACA), individuals and small businesses are able to enroll in select health plans through the state health insurance exchange, Covered California, as well as through individual carriers. An essential benefit required to be offered by these plans is pediatric vision care. The benefit includes an annual eye exam and glasses for children up to 19 years of age; low vision is also covered. Most health plans in the exchange contract with a vision plan to provide the pediatric vision essential benefit required under the law. Vision care for adults is not considered an essential health benefit under ACA and is not offered in Covered California plans. However, in an effort to help Californians of all ages access vision coverage, Covered California is contracting with certain vision insurance companies to offer vision coverage directly to adult consumers; https://www.coveredca.com/individuals-and-families/getting-covered/vision/.

Note: You are not automatically a Covered California provider if you are already contracted with a health plan that offers Covered California products. You must contact each health plan directly to verify your provider status and to request an application for its Covered California panel. Each plan offered through Covered California has an independent contracting process. For information on individual health plans, see https://www.coveredca.com/individuals-and-families/getting-covered/health-insurance-through-covered-california/. For information on small business plans, see https://www.coveredca.com/forsmallbusiness/plans/.