Program Overview
The EyeMed PLUS Provider Program is a voluntary network that allows optometrists, ophthalmologists, and other eyecare professionals to receive higher reimbursement rates for services rendered to EyeMed members. By joining the program, providers gain access to a larger patient pool, marketing support, and tools designed to streamline claims processing.
EyeMed, a leading visionbenefit administrator in the United States, created the PLUS program to reward providers who consistently deliver highquality care, maintain efficient billing practices, and engage in ongoing professional development. Participation is optional, and providers retain the freedom to opt out at any time.
Key Benefits for Providers
- Increased Reimbursement: PLUS participants receive a tiered boost over standard rates, often ranging from 5% to 15% depending on the service category.
- Expanded Patient Base: EyeMed promotes participating providers through its member portal, email newsletters, and mobile app, driving new appointments.
- Streamlined Claims: Integrated electronic claim submission tools reduce paperwork and accelerate payment cycles.
- Continuing Education: Free webinars and workshops on the latest clinical techniques, practice management, and compliance requirements.
- Performance Analytics: Quarterly reports highlight claim volume, denial rates, and patient satisfaction metrics.
- Marketing Materials: Customizable flyers, digital banners, and socialmedia assets help providers showcase their EyeMed affiliation.
Eligibility Requirements
To qualify for the EyeMed PLUS Provider Program, a practice must meet the following criteria:
- Hold a valid, active license to practice eye care in the state of operation.
- Be a current EyeMed network provider with a clean compliance history (no unresolved fraud or abuse investigations).
- Demonstrate a minimum of 200 processed EyeMed claims in the previous 12month period.
- Agree to submit claims electronically using the EyeMed Provider Portal or an approved clearinghouse.
- Commit to completing the annual provider education module within the specified deadline.
Providers that fall short of any single requirement may still be considered on a casebycase basis if they can provide compelling justification.
How to Enroll
Enrollment is a straightforward threestep process:
| Step | Action | Estimated Time |
|---|---|---|
| 1 | Log in to the EyeMed Provider Portal using your existing credentials. | 5minutes |
| 2 | Navigate to Programs EyeMed PLUS and complete the online application, providing practice details, NPI number, and a recent claims summary. | 1015minutes |
| 3 | Upload required documents (license copy, malpractice insurance, and a signed participation agreement). Submit for review. | 5minutes |
After submission, the EyeMed provider relations team reviews the application within 710 business days. Successful applicants receive a confirmation email with a unique PLUS provider identifier and access to the enhanced reimbursement schedule.
Reimbursement Structure
Reimbursement rates for PLUS participants are tiered based on service type and volume. The table below illustrates a typical structure for primary eyecare services (rates are illustrative and may vary by region):
| Service Category | Standard Rate (USD) | PLUS Rate (USD) | PLUS Increment |
|---|---|---|---|
| Comprehensive Eye Exam | $35 | $40 | +14% |
| Contact Lens Fitting | $50 | $58 | +16% |
| Glaucoma Screening | $45 | $51 | +13% |
| Lens Replacement (single vision) | $120 | $138 | +15% |
| Lens Replacement (progressive) | $180 | $207 | +15% |
Additional bonuses may be applied for highvolume providers (e.g., an extra 2% for exceeding 500 claims per quarter). All payments are made via direct deposit within 30 days of claim acceptance.
Frequently Asked Questions
Can I remain in the standard EyeMed network while also joining PLUS?
Yes. Participation in the PLUS program does not affect your existing relationship with the standard EyeMed network. All claims are processed as usual; the only difference is the higher rate applied to eligible services.
What happens if a claim is denied?
Denials are handled through the same appeals process used for standard claims. The provider portal provides realtime denial codes and suggested corrective actions to reduce future rejections.
Is there an annual fee for the PLUS program?
No. EyeMed does not charge a membership fee. The program is funded through the incremental reimbursement rates that participating providers receive.
Do I need to update my electronic health record (EHR) system?
Only if your current EHR does not support EyeMeds electronic claim format (ANSI X12 837). Most major EHR vendors have already integrated the necessary modules, but you can also submit claims through a certified clearinghouse.
How often are the reimbursement rates reviewed?
EyeMed conducts an annual rate review based on market conditions, cost of services, and utilization data. Providers receive a 60day notice before any changes take effect.
Can I opt out of the PLUS program after joining?
Yes. Providers may withdraw at any time by contacting their EyeMed account manager. All claims submitted while you were a PLUS participant will continue to be paid at the PLUS rate.
