Electronic Forms Transfer (EFT)
EFT is available to participating providers who are interested in receiving payment electronically. Once OptiCare has received a completed EFT agreement, please allow four weeks before the first deposit is completed electronically to your account.
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Georgia Correction Industries (GCI) Eyeglass Order Form
Providers using GCI to order eyeglasses should use this form to place their order.
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Essilor Provider Application
Providers using Essilor/Southern Optical must set up an account with Essilor. This form should be completed and sent directly to Essilor for processing.
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Request Login for OptiCare's Online Eye Health Manager
Please download the form, complete and return it to the Network Development Department at toll-free fax number (800) 980-4002
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Request for Claim Review (Single Claim Only)
When requesting an informal or formal claim review and there is only one claim, please use this form. Please follow all instructions listed on the form.
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Request for Claim Review (Multiple Claim or Batch)
When requesting an informal or formal claim review and the appeal is similar and involves multiple claims, please use this form. Please follow all instructions listed on the form.
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Prior Notification Form
This form should be completed and faxed to the OptiCare Medical Management department when a patient requires medically necessary contact lenses for reasons other than Keratoconus , Aphakia, or for a bandage.
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Peach State Acknowledgement of Financial Responsibility form
Please download the form and use it when the member has requested materials that are over and above the plan benefits and is aware that there is a patient payment responsibility. Please ensure that the patient completes the “To be completed by Member” section. Members must sign the form, or if the member is under eighteen (18) the form should be signed by a parent or guardian. Providers should complete the “To be completed by OptiCare Medicaid Provider” section. Retain the form in the patient’s record.
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Special Request form
Please download the form and use it when you are dispensing contact lenses to a patient for a medical reason other than aphakia, keratoconus, or a bandage contact lens. Fax the form to: 252-451-2908.
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State of Georgia Medicaid ID Numbers
Providers for the Peach State Health Plans must have a State of Georgia Medicaid ID number. The following link will take you to the Georgia Health Partnership home page, where you can apply for one.
www.ghp.georgia.gov/wps/portal
