Your provider number, your responsibility: billing essentials for optometrists

Getting billing right is critical to professional practice. Whether you’re an employee, contractor, locum or practice owner, you need to understand your responsibilities when claiming from Medicare, DVA or private health insurers.

Practice managers and administrative staff can help with billing and processing claims.

But if a claim is made under your provider number, you’re responsible for understanding what is being claimed in your name and making sure it is appropriate.

The key message is simple: Your provider number, your responsibility.

That doesn’t mean you need to manage every administrative step yourself.

It does mean you should understand how your services are being billed and speak up if something doesn’t look right.

Medicare: make sure your item-code claim is appropriate

The optometrist who provided the service is responsible for the Medicare claim, regardless of their employment or contractual arrangements.

Before claiming, make sure you:

• select the Medicare item code that accurately reflects the service provided. There are 3 golden rules for any Medicare billing:

1. Check that the service meets the specific descriptor of the relevant MBS item;
2. Is the service clinically necessarily?; and
3. Would a panel of your own peers agree with your billing?

• review rejected claims yourself before another item code is chosen and resubmitted
• if you are a locum, consider adding ‘ use 109xx if rejected‘ in your patient clinical file. If you’re hiring locums – implement an onboarding step for locums where locums are required to add this information
• practice staff can help with the administrative side of claiming but the treating optometrist should be satisfied that the claimed item accurately reflects the service provided

If someone else is choosing Medicare item numbers (including re-submitted ones) on your behalf, particularly an employer or practice staff, we advise that you bring up the concern immediately or call OA helpdesk for advice.

Department of Veterans Affairs (DVA): understand the requirements

DVA has its own fee schedules and claiming requirements for optometrists and optical dispensers.

Before making a DVA claim, check that you:

• are using the correct DVA item number
• have checked the current DVA fee and optical appliance fee schedules
• have confirmed the patient’s eligibility

Again, the treating optometrist’s provider number should be used for the DVA service or appliance claim.

Tip: Alternatively, optical dispensers can also register as a DVA provider. This mitigates the issue where the optometrist no longer works at the practice. Optical dispenser can apply to be a DVA provider via the registration form on DVA’s page

Private health funds check the fund rules

Claiming of optical appliances via private health funds can vary between health funds. Optometry Australia will continue to advocate for more consistency regarding rules between Health Funds.

OA’s Private Health Insurance Rules & Rebate Conditions member guide was designed to cover common claiming questions, assist optometrists in navigating the variance in rules, including which provider number to use when an optometrist isn’t present when a claim is processed.

Again, your provider number should only be used if you provided the service.

Tip: We also recommend that the practice applies for a ‘store provider number’, sometimes called the ‘practice provider number’. The use of a store provider number for the dispensing of optical aids (spectacles and contact lenses) means the optometrist’s own provider number does not need to be used when the optometrist is not present or did not provide the service.

• Go to Medibank’s page, scroll down to ‘optical dispenser’ and click on ‘application form’
• Once you have a store/practice provider number, you will be able to claim via Hicaps for all the other health funds too. You do not need to re-apply for additional health funds

Key messages for Health Fund claiming:

• Don’t use an individual optometrist’s provider number simply because it is available in the practice system
• Apply for a store provider number
• make sure the provider number used meets the fund’s requirements

Provider numbers: use the right one

A provider number isn’t simply an administrative identifier that anyone can use when processing a claim.

It’s particularly important to get this right when:

• an optometrist is part-time or not working that day
• a practice manager or staff is processing claims
• multiple optometrists work at the same practice

Your provider number, whether it’s for Medicare, DVA or Health Fund claiming, should not become the practice’s default billing number, especially if you were not the provider who provided the service.

Practices should have clear systems to ensure claims are submitted under the appropriate provider or entity and in line with the requirements of the relevant scheme or health fund.

New graduates: ask questions

Billing can be a lot to take in when you’re starting out. If you’re unsure about a Medicare item, DVA claim or private health rebate, ask your employer or call OA’s confidential help desk.

If you feel pressured to make a claim, or your provider is being routinely used for patients you have not seen:

stop and check the relevant requirements (e.g. check OA’s Optometry Items Summary Table, Billing with Confidence guide, and Health Fund Rules Guide)

Raise your concerns with your practice. If you’re unsure how to or just need to sense-check the rules or your obligations, contact OA helpdesk for confidential advice.

Employees, contractors and practice owners

Whether you’re an employee, contractor, or practice owner, your professional responsibility to claim appropriately remains.

Employers and practice owners can set up administrative processes, and staff can help process claims. But where a claim is made under your provider number, you should understand what is being claimed and be satisfied that it is accurate and appropriate.

Good billing practices are a shared responsibility. Clear processes, appropriate training and a workplace where optometrists can raise concerns all play a part.

Not every incorrect claim is delibrate. If something doesn’t look right, ask

Not every incorrect claim is deliberate. Mistakes can happen because information is out of date, software has been configured incorrectly, or workplace processes aren’t clear.

If you discover that a claim made under your provider number may be incorrect, don’t ignore it.

Check the relevant requirements, raise it with your practice and seek advice about what to do next.

Need advice? OA is here to help

All members, including new graduates, are encouraged to seek independent advice from OA. If you’re simply unsure which Medicare item is appropriate, or if you suspect your provider number is not being used appropriately.

We can assist in helping optometrists – raise concerns and find resolutions, reasonably and confidently.

The Optometrist Advisor Help Desk provides confidential, one-on-one support to OA members on Medicare and private billing, DVA, health fund claiming rules, workplace issues, ethical concerns, audits and other professional matters.

Call 1800 678 662 or email OAhelpdesk@optometry.org.au.

Getting claims right helps protect patients, practitioners and the integrity of Australia’s eye health system.

Your provider number, your responsibility. When in doubt: check, ask and seek advice.

OA member resources we recommend you download:

• Medicare – Optometry items summary table (effective 1 July 2026) PDF
• Medicare – Billing with Confidence PDF
• OA Private Health Fund Rules (PDF)