Nikole is out-of-network with all insurance companies. What does this mean?
This means that your lactation services would be paid for out of pocket. Thanks to federal and state legislation you should be able to receive reimbursement from your insurance company. After your consult you will be provided with a superbill to submit to your insurance provider to request reimbursement. There is no guarantee that all or any of the amount will be reimbursed. Many times, the outcome of the submitted claim is determined by how much the plan participant pursues the insurance company for reimbursement.
If your insurance company has in-network lactation consultants, your options are to seek services from an in-network provider or to use out-of-network benefits if your plan includes them. Out-of-network benefits vary by company and plan, you can reach out to your insurance plan provider to request more information about your out-of-network options.
If your insurance company does not have any in network providers, they may reimburse an out-of-network service at an in-network rate. You can reach out to your insurance company to find out if this is an option, and what you would need to do to obtain reimbursement. Some insurance companies may request that you submit a gap acceptation along with your superbill.
What does the Affordable Care Act provide?
The Affordable Care Act states that all Health insurance plans must provide breastfeeding support, counseling, and equipment for the duration of breastfeeding (this does not apply to grandfathered plans). These services may be provided before and after birth. You can learn more here: Affordable Care Act
How do I understand my rights about the Affordable Care Act?
It can be confusing and intimidating to submit a claim or file an appeal to an insurance company. The National Women’s’ Law Center has put together a wonderful tool kit to help. You can learn more here: NWLC Tool Kit
Is there any specific legislation in NJ?
The 2021 NJ Revised Stature 17 not only include what is required to be covered in regards to lactation support, it also includes what is not required in order to receive that coverage. This includes information about location visit, when the services are available, and not requiring referral, prior authorization, or medical necessity for lactation counseling services. You can learn more here: 2021 NJ Revised Statute 17
Do you have any other tips?
If being reimbursed for lactation services is important to you, it’s always important to call your insurance company before booking an appointment. When speaking with your insurance company be sure to find out:
- The representative’s name and a confirmation number for the call if possible. Also note the date and time of the call.
- What your policy includes in regards to breastfeeding/lactation support (number of visits, location requirements, codes covered, etc.).
- If they require you to see an in-network provider, request a list for your area.
- If they do not have any in-network options, or they cannot offer a list of providers, find out how much they will reimburse you for obtaining support from an out-of-network provider.
- Ask them if you are required to submit a gap exception and how to do so.
- Ask them what their procedure is for submitting a claim for reimbursement.
If they ask for information about the specific services, here is my NPI number is 1912405622. The most common procedure codes used for services are 99401, 99402, 99403, and S9443 with the diagnosis code Z39.1.
Remember: If they deny your claim you can file an appeal. You can also submit a complaint to the State Insurance Commissioner citing the laws and statues included above. You can learn more here: State of NJ Banking and Insurance Complaint