FREQUENTLY ASKED INSURANCE AND BILLING QUESTIONS
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Does Premier Lactation Services participate with insurance plans?
Yes. In some cases we bill the insurance carrier directly. For others, we provide a Super Bill to facilitate the reimbursement process for our clients. (See our Super Bill Service in response to question 6, below. A Super Bill is an insurance claim document containing procedural and diagnostic coding as well as our provider identification information. This is the document recognized by insurance companies as reimbursable for out-of-network claims).
Which insurance carriers does Premier Lactation Services participate with as an in-network provider?
We are currently in-network with Aetna. This means we will bill them directly for the services we provide. As part of our exceptional services, we will perform an assessment and make recommendations for both the lactating parent and the baby. This enables us to bill Aetna for both clients.
Does Aetna impose any restrictions on payment for services?
Yes. Sometimes cost-sharing is applied after a certain number of visits or even for the baby’s portion of the initial visit. This seems to be dependent on the individual plan. In these cases, we will resubmit the claim or appeal cost-sharing one time per visit and then bill you for the amount applied to deductible, coinsurance, or patient responsibility.
What happens if I have Aetna insurance but my baby does not?
In these situations, we bill Aetna for your portion of the visit and charge an out-of-network fee for the baby’s portion of the visit.
What happens if my baby has Aetna but I do not?
We will bill you our “out-of-pocket” fee for the entire visit and submit a claim for the baby. We will also provide you with a Super Bill so that you can pursue reimbursement from your insurance company. If Aetna pays us for the baby, we will reimburse you that amount.
What if I have an insurance carrier other than Aetna?
For all other insurances, we provide something called a “Super Bill” that will allow you to submit to your insurance company for reimbursement. We would collect payment at the time of the visit. You may pay for the visit however you like; card, cash, or check.
What if I have Tricare as my insurance provider?
We are Tricare “precertified” which will facilitate the reimbursement process for our families with Tricare Insurance.
Can I use my HSA/FSA card to pay for services?
Yes, we are able to process your HSA/FSA card for payment. However, if you use your FSA/HSA card, you cannot also submit a super bill for reimbursement from your insurance company.
Will my out-of-network insurance provide reimbursement for your services?
In many cases, yes! The Affordable Care Act mandates that health insurance plans must provide breastfeeding support, counseling, and equipment for the duration of breastfeeding. These services may be provided before and after birth. Sometimes insurance carriers appear to ignore this portion of the law.
What is being done to ensure that insurance carriers are compliant with this law?
There have been lawsuits brought against several insurance companies for not complying with this portion of the Affordable Care Act. Our industry continues to lobby Congress and the executive branch agencies to enforce these regulations.
I plan to call my insurance carrier in advance to see what they may cover. What information do they need?
Your insurance representative may ask for the following information:
- CPT or procedure codes: S9443 and 99404
- Diagnosis code: Z39.1
- NPI: 1063749083
- Tax ID: 87-3975211
I have a Virginia Medicaid policy. Will you be able to bill them or will I submit for reimbursement?
At this time, we are, unfortunately, not able to bill Medicaid policies for lactation services. Be advised that they are also not likely to reimburse you, even with the Super Bill that we provide to you.
I ordered a pump or took prenatal lactation classes that were billed to my insurance. Will this affect my lactation coverage?
Yes, possibly. One company in particular, is billing insurance for codes that we typically use for lactation services. Many clients are being told that they have already reached their “max allowable” use of these codes and are therefore, having a portion of the initial visit being applied to deductible, co-insurance, or patient responsibility. Please let your lactation consultant know if you think this is a possibility.