Insurance Coverage for Breast pumps and Lactation Consultant Visits

The insurance company said that my breast pump is covered if it is "Medically Necessary." What does that mean?

The insurance company determines whether products or services are "medically necessary" based on coding information. One system is the ICD-9 coding system: it uses numbers to represent different medical diagnoses. Your healthcare provider or lactation consultant writes the diagnosis codes for you and/or your baby on the office billing form that is used for insurance claims. ICD-9 or diagnosis codes tell your insurance company why you and/or your baby need medical products and services, such as a breast pump and/or a lactation consultant visit. Knowing this information can be a powerful tool when you communicate with your insurance company. ICD-9 codes help you speak the "same language," allowing you to emphasize why the breast pump is medically necessary (in the insurance company's terms) for you and your baby, and therefore, why it should be covered by your insurance plan.

Here are some common ICD-9 (Diagnosis) codes associated with the medical need for breastfeeding-related products, equipment and lactation consultations:

COMMON ICD-9 CODES/DIAGNOSIS CODES:

Some Examples of Using Coding in Conversation with Your Insurance Company

My lactation consultant has indicated that I have retracted nipples, ICD-9 code 676.0. The use of a breast pump is medically necessary for me to resolve this medical problem in order to successfully breastfeed and provide nourishment to my baby.

The pediatrician has diagnosed my premature baby with ICD-9 code 783.3, Feeding Difficulty-Infant, and has prescribed the use of a breast pump so that I can continue to provide breastmilk for my baby while he remains in the neonatal intensive care unit. Because this is medically necessary for my child, I need to know how to submit a request or claim for reimbursement for the prescribed breast pump, (Brand/type), purchased (or rented) on (date).

My baby has jaundice, ICD-9 code 774.39, and my pediatrician has indicated that I need to pump breastmilk to provide my baby with more frequent feedings so that she can excrete the excess bilirubin and resolve this medical condition of jaundice. Because this is medically necessary for my child, I need to know how to submit a request or claim for reimbursement for the prescribed breast pump, (Brand/type), purchased (or rented) on (date).



What is Prior Authorization?

Your health insurance plan may require "prior authorization" before the insurance company agrees to cover (or pay for) certain medical services or equipment. Prior authorization means approval by an insurance company for the patient to receive medical products, tests or surgical procedures before they are given. Prior authorization is a way that insurance companies ensure that the prescribed treatment is medically necessary. In other words, the insurance company does not want to pay for medical equipment or services that are not really needed. Through the prior authorization process they can learn more about the patient's health condition and why the equipment or service is needed before they decide whether to reimburse for it. They decide this based on information that your healthcare provider gives to them.

How do you know if your insurance company requires prior authorization? Call the Member Services Department phone number on your insurance card and ask. If you talk with a customer service representative who seems unsure, ask to speak to a supervisor or to be connected with the "Pre-certification Department."

The prior authorization process can vary depending upon what your insurance plan requires. For some insurance plans, your doctor or lactation consultant may have to call or send a special letter called a "Statement of Medical Necessity" or "Letter of Medical Necessity." (See Appendix, page 27.) In other words, this call or letter is sometimes needed in addition to a written prescription for a breast pump. It often helps to also include a Letter of Medical Necessity from your baby's physician or your lactation consultant indicating why he/she has prescribed the equipment and services for you.

When you call your insurance company about prior authorization, here are important questions to ask:

·         Does my plan require prior authorization for coverage of this particular service or product? (For example, Does my plan require prior authorization for a manual or electric breast pump? Do I have to get prior approval for my appointment to see a lactation consultant?)

·         How do I get prior authorization for something? What is the process?

·         What is the fax number or address to which I will send the request (or phone number to call)?

·         What information do I need to send? (What paperwork or proof do they need?)

·         How long will it take to hear if it is approved?
(If they say they are "not sure," ask "How long does it usually take?")

·         If prior authorization is approved, how long is it good for or when will the approval time "expire?" (e.g., How many lactation consultant visits can be approved? Is the approval for any breast pump or is there a specific type of breast pump I must get-manual/electric?)

·         How will I find out whether or not it has been approved?

How do I file a claim with my insurance company for a breastpump and/or lactation services?

Some providers can file a claim for you if you provide them with information about your insurance plan. Often, providers make a copy of your insurance or Medicaid card; they fill out the claim paperwork and file it with your insurance company as a convenience to you. Sometimes, due to office policies, they may not be able to do this for you. You may be asked to pay for a breast pump when you receive it or to pay when you see a lactation consultant for services. Your lactation consultant or healthcare provider may give you a receipt for the breast pump supplies and/or a copy of their office billing form. They may suggest that you then submit a claim directly to your insurance company. Medela encourages you to do this because you may be entitled to receive payment back from your insurance company for the money you spent on your breast pump/services. This involves sending a copy of the receipt/billing form (always keep a copy for your records) along with a claim form or letter to your insurance company. Your insurance company has specific requirements for how to do this and the following provides helpful hints about filing claims on your own.

·         The first step is to call your insurance company and ask how to file a claim correctly - you may need to request the proper claim form from your employer's benefits department or you can ask your insurance company to mail one to you.

·         Follow the instructions on the claim form. Be sure to include complete information in the following areas:
. Patient's full name, address and phone number
. Patient's Social Security number
. Patient's date of birth and gender
. Policy and group number
. Policy holder's name, if different from patient
. Policy holder's relationship to patient

·         Attach a copy of the receipt to the claim form.

·         Check the claim form for completeness and accuracy.

·         Be sure to sign the claim form.

·         Make a copy of the claim form and all attachments (i.e., receipts, etc.) for your records.

·         Mail the claim form and all attachments to the claims department of your insurance company. For your records, write down the date you mail the claim form and attachments. Knowing this date is helpful when you call to check the status of your claim. It often takes awhile for insurance companies to process claims and knowing when you sent your claim will help.

It is important to know that insurance companies require a claim to be submitted within a specified period of time from the date the medical services were provided (or from when you bought or rented your breast pump). This filing time limit is often one year from the date of service. Claims submitted outside of the required time frame may not be considered for payment. Act quickly as you may not be reimbursed at all if you do not file the claim within the required time period.


How will I know if my insurance company has reviewed my claim?

It is common for claims to take up to four to six weeks to process. If payment has not been received within six weeks of submission, you should call your insurance company to check on the status of your claim. The customer service department is the best place to start.

Before you call, have the following information in front of you:

·         Your insurance card (with your identification/group number, plan information, etc.)

·         Pen and Paper (To write down the names of customer service representatives and any important information they give, as well as the date/time of your call)

·         Date of service (This is the date you saw the lactation consultant/received your breast pump/supplies)

·         Type/Name of breast pump for which the claim was submitted

·         Name of provider that performed the service or dispensed the breast pump

·         Total amount you paid and submitted for reimbursement

Here are some questions to ask your insurance company representative:

·         I'm calling to check on the status of my claim for date of service, (insert date). What date was the claim received?

·         Has it been processed yet?

·         (If not processed yet): When can I expect the claim to be processed?

·         (If claim has been processed): What was the covered or allowed amount? What is the amount paid (the amount of reimbursement to be received)?

·         (If claim has been processed): When was payment issued and to whom?

·         (If claim has not been received): How long does it take after receiving a claim to have it logged into the system for processing? When should I call back to check again? Should I resubmit the claim?

How do I appeal if my claim is denied?

Often a claim denial can be attributed to errors or incomplete information. In these cases, you or your healthcare provider can simply make the necessary corrections, attach additional information about why the equipment/services are needed and then resubmit the claim.

Even if you do everything correctly and completely, your insurance company may still deny your request for reimbursement. It is important for you to remember that an initial denial is not final and may be overturned if you appeal.

An appeal is a written request to your insurance company for further review of a denied claim or service. How you appeal a denied claim will vary among health plans. Call your insurance company and tell them that you wish to appeal a claim that was denied and that you need to know what their appeal process requires.

Here are some questions to ask your insurance company representative:

·         Why was the claim denied?

·         Who must initiate the appeal (you or your provider)?

·         What do I need to send and to what address?

·         How long will it take to process the appeal?

In most cases, you or your healthcare provider will be required to write an Appeal Letter (see Appendix, pages 29 & 30). In this letter, be sure to include information about the medical reasons why you need to pump breastmilk and/or why you need the services of a lactation consultant. This could be if your healthcare provider has indicated that your baby needs breastmilk (benefits of breastmilk, formula allergy) or if your baby has some other special need that requires you to pump your breastmilk.

A Letter of Medical Necessity from your healthcare provider may or may not be required with your appeal. In the Appendix of this guide, there is a sample "Claim Denial Appeal Letter." Even if not required, a letter from your healthcare provider (baby's pediatrician/neonatologist or your lactation consultant) can be very helpful in supporting your position (refer to the Appendix). No matter what type of insurance you have, it is your right to appeal a denial.

Sometimes a claim denial is due to specific exclusions or restrictions included in a particular health plan. Specific exclusions or restrictions are services or products that are not covered by your health plan. If your claim is denied because the service or products are specifically not covered by your health plan, you may need to file a grievance. As with the appeal processes, the process for filing a grievance will vary from health plan to health plan. Be sure to call your health plan's customer service department to obtain the specific details. Calling for the specific details is important when submitting a claim denial appeal or filing a grievance.

As a health plan customer, you have the right to be heard; keep in mind that the insurance company also has the right to approve or deny your request. The following section will give you some tips for communicating with your insurance company and will help you get the most out of your healthcare benefits. It is important to know that appealed claims are typically successful if the appeal letter and documentation includes information that supports the medical need.



Helpful Hints for Dealing with Your Health Insurance Company

You are in charge of your healthcare needs as well as your baby's. Knowing your insurance benefits and communicating effectively can increase your chances of having your breastfeeding-related equipment and services covered and reimbursed by your insurance.

The following are helpful hints for dealing with your insurance company:

·         Be confident when calling your insurance company. As a valued customer, you have the right to receive complete information regarding your health benefits. Your insurance company's customer service representatives are there to assist you. Part of their job includes answering questions to your satisfaction.

·         Communicate clearly and calmly. Remember that your ultimate goal is to get coverage for what you and your baby need. If you are met with resistance, simply restate your request.

·         Don't give up. Don't take "No" for an answer. If you have tried discussing your request with your health plan's customer service representative, but are not satisfied with how your insurance matter was handled, ask to speak to:

·         a Supervisor in the Customer Service Department

·         the Manager or Director of Customer Service or Member Services

·         Know your benefits. Health insurance plans can be confusing. However, you are responsible for knowing what benefits you are entitled to under your policy. If you do not fully understand something, ask your insurance representative or your employer's benefits administrator.

·         Keep track of all communications with your insurance company. Be sure to keep detailed, written records of each conversation you have with your insurance company representatives. Record the date the conversation took place, the first and last names of the representative with whom you spoke and make notes regarding any information that was provided to you. Also, remember to keep copies of all written correspondence that has taken place between you and your insurer.

·         Follow up in writing after speaking with a health plan representative on the phone. Keep your correspondence simple and to the point. Include relevant dates, names of representatives with whom you spoke and what they told you. Also, be sure to include your name, policy number and any other identifying information. Do not hesitate to ask for help from your employer's Human Resources department and your healthcare provider or lactation consultant. In many cases, your employer makes decisions about what will and will not be covered under your health plan. Your employer's support may result in the approval of your request for coverage. Having your healthcare provider contact your insurance representative can also be helpful since he/she can support the communication that you have had with your insurance company as to why the requested medical products or services are needed for your baby's overall health.

·         Carefully follow the steps outlined by your health plan for requesting prior authorization, submitting claims or filing appeals. Not following these steps may result in a delay in processing or a denial of your request for coverage.

·         Advocate at all levels. Write to your state health insurance commissioner (see Appendix for Directory of Insurance Commissioners, beginning on page 34) and/or your state and Federally-elected representatives and enlist their help by informing them of your health needs and what has occurred with your health plan insurance claims. Notify your insurance company that you have requested help from the state health insurance commission and other agency representatives in resolving difficulties in meeting your healthcare needs.

·         Be persistent! Remember that a denial is not necessarily the final word. Ask your insurance company to reconsider their decision and follow-up to make sure they are taking action.

·         You can make a difference! Medical directors at insurance companies have indicated that they would be more likely to expand coverage for breastpumps and lactation consultant services if their customers were actually requesting coverage. Enclosed in this guide are several helpful letters (see Appendix, pages 26-37) that can be used to initiate prior authorization or to notify your insurance company of the medical necessity for breastfeeding-related supplies and services. Two of the letters are claim denial letters (one from you and one from your healthcare provider to your insurance company). The prior authorization letter can be used to request coverage for your breastpump/supplies before you make the purchase or rental. The other sample letters are useful to send to your employer and your state insurance commissioner/representative to inform them of the need for this important healthcare benefit. Remember that expression, "the squeaky wheel gets the grease." The more you make the needs of you and your baby known, the more likely you will get those needs met!