Eyecare Practice Owner's Guide to Medical Credentialing

Posted by Madhu Singh on Thu, Mar 05, 2020 @ 08:03 AM

For anyone who owns their own practice, medical credentialing is probably something you're familiar with. If you're researching what you need to open your own optometry practice or to move to a different state, then you'll need to know how the medical credentialing process works for ODs.

In order to work with insurance providers, you'll need to complete a review. Jerry Godwin from OMS provided us with his intelligence on medical credentialing from starting the process to what happens after you've been approved. Keep reading to make sure you're in compliance with your state's laws and requirements.

The Complete Guide to Medical Credentialing for ODs 

CertificationMedical Credentialing

Medical credentialing is not only a critical component of developing a practice that delivers the highest level of patient care, it’s essential for insurance reimbursement. Through the credentialing process, states and insurance providers determine which medical providers meet their requirements. Doctor credentialing reviews a host of different pieces of information for each medical professional, including:

  • Education and training
  • Residency
  • Licensing
  • Specialty certificates
  • Qualifications
  • Career (work) history

A medical professional must complete this review when they start at a new practice or change states. Medical credentialing consists of a few different processes: provider credentialing, provider enrollment, and privileging.

  • Provider Credentialing: the process of verifying the skills, training, licensing, qualifications, etc.
  • Provider Enrollment: the process of enrolling a provider with insurance plans.
  • Privileging: approving providers to perform specific procedures and granting them a specific set of privileges (not required for Optometrists usually).

Things to Know About Credentialing

What do you need to know before signing up for credentialing in any given state or market?

  • Credentialing can take anywhere from 90 to 150 days, depending on the time of the year. Usually 45-60 days to gather and complete provider data and another 90 days for the approval of the documents from the insurance carriers.
  • Make sure the application paperwork completed accurately and completely. Missing information, such
    as work history, current work status, the state of your malpractice insurance or any current hospital
    privileges you have should all be included.
  • Staying current with relevant organizations, like the Coalition for Affordable Quality Healthcare (CAQH), can help make your credentialing process a little simpler. Don’t forget your CAQH attestations — the paperwork that ensures your forms are accurate and valid. If you must change any information after the application has been completed, you’ll have to rewrite and resubmit your attestation.
  • Each state has specific credentialing laws and regulations, so make sure you’re aware of any particular rules that could apply to your situation.
  • Note: With some commercial payers contracting is done separately from credentialing.

Commercial Insurance Credentialing

The provider is both credentialed and contracted with the insurance company simultaneously.  The provider cannot be credentialed without a contract nor can you have a contract without the provider. The first step is to enter into a contract, and either simultaneously or after the contract is in place, the insurance company will credential the provider for new business and link them to that contract.

Re-credentialing

Re-credentialing, also known as re-enrollment and revalidation, occurs periodically and requires a provider to repeat the credentialing process. Providers will receive a letter letting them know that they are up for re-credentialing and have a specific deadline to complete the process. If they do not complete this within the deadline, their credentialing status is suspended and the provider is deemed out of network with the insurance company.  The provider can request to have a deadline extension, but if that is not possible, the provider will have to credential as a new provider once again.


There's still a lot more to know about setting up your claims process for success. Follow our guide below.

Download Your Guide

Tags: Practice Efficiency, Electronic Claim Filing

Looking for tips to grow your eyecare practice business? Read on!