INSURANCE AND LACTATION SERVICES
What your insurance doesn't want you to know
I am in-network with some insurers through Lactation Network. If you want to go through them, there is a $75 convenience fee in addition to fees for traveling to you beyond a 15-mile radius of Maplewood, NJ.
What happens if I'm not in-network with your insurance through Lactation Network? Here's how you can be reimbursed for your visit.
Insurers make it very difficult for lactation providers to become in-network so most of us are not. What that means is that they are then required to cover out-of-network lactation visits. According to the National Women's Law Center's Toolkit: If your insurance company doesn’t have any lactation consultants or breast pump providers in-network, the insurance company must cover services from an out-of-network provider without cost-sharing. Federal guidance makes clear that “if a plan or issuer does not have in its network a provider who can provide the particular service, then the plan or issuer must cover the item or service when performed by an out-of-network provider and not impose cost-sharing with respect to the item or service.” If your insurance company does not have providers in its network to provide breastfeeding equipment or lactation counseling, you must be able to go out-of-network, the item or service must be covered, and covered at no cost-sharing.
Getting an exemption:
If they tell you they won't cover a visit, you should request a network (or gap) exemption for at least 2-4 visits.
Here is the information they will need:
Provider: Danielle Tropea
(I will provide you with my EIN and address over the phone.)
IBCLC certification #: L-84572
Codes most likely used:
Diagnosis Code z39.1
Procedure Code 99404, s9443, 99204
Please make sure to keep the name of the representative you spoke with and get a reference number.
At the conclusion of our consultation and paying my fee, I will provide you with a superbill which serves as a statement and receipt. You will then submit it along with any necessary claim forms to your insurer. I will include travel and parking fees to the superbill.
MOST of the time insurers will reimburse the claim with no issue. Occasionally, they may deny the claim so it's important to find out why. Sometimes it needs to be submitted under the baby's insurance instead of the mother's or a referral from your pediatrician or OB/GYN is needed. Other times they are only willing to reimburse under different codes. Let me know and I will provide you with an updated superbill.
If they still refuse, you can use this letter to appeal.
Under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act), insurers are required to cover breastfeeding support, supplies, and counseling. The exact language is "The Women's Preventive Services Initiative recommends comprehensive lactation support services (including counseling, education, and breastfeeding equipment and supplies) during the antenatal, perinatal, and the postpartum period to ensure the successful initiation and maintenance of breastfeeding."
In New Jersey:
New Jersey law requires "health insurers... to provide coverage without requiring any cost-sharing, for expenses incurred in the provision of breastfeeding support and counseling before or after the birth of an infant and the provision of a breast pump."
Please complain to the New Jersey Department of Banking and Insurance if they refuse to reimburse you.