Submitting for Insurance Reimbursement for IBCLC Care

The Affordable Care Act of 2012 requires coverage of lactation consulting as a “Women’s Preventive Service.

Please contact your insurance company to learn specifics for your plan. If Breastfeeding Success Company not your in network provider, our lactation consultants will accept payment on the day of the consult and provide you with the receipt necessary for you to seek insurance reimbursement.

This list is for informational purposes only – no healthcare provider can tell you what your insurance will or will not cover.

We suggest following these steps to get specific information for your insurance plan and processes:

  1. Call your insurance company and ask if they have any particular instructions or forms they require.
  2. Your IBCLC will give you a receipt – known as a superbill – which includes:
    • A National Provider Identification (NPI) number and tax ID (EIN) number.
    • A code for the type of appointment (CPT code), such as a home visit.
    • A code for the problem (ICD-10 code), such as slow weight gain in newborn.
    • The amount you paid.
    • The date of service.
    • The IBCLC’s contact info and signature.
  3. You should mail or fax this superbill, together with your policy information, to your insurance company, according to their instructions.

If your claim is denied

Because coverage of lactation services is new for many insurers, some companies are still sorting out what to cover, and confusion is common. These suggestions may help if you have difficulty getting reimbursement.

  • Make sure you understand the reason – occasionally a claim just needs to be resubmitted under the mother’s name instead of the baby’s, or vice versa, or more information is necessary. Some companies may ask for a referral from your pediatrician or ObGyn.
  • If you are told that you must see a provider in your network, or a provider who is a doctor or nurse practitioner, request a list of IBCLC providers that you can see. If they do not provide one, consider appealing your claim, because this is not meaningful coverage. (See this information about appeals.)
  • Some insurance companies are still unfamiliar with the IBCLC credential. They may ask for a copy of your provider’s state license – There are only a few states in the U.S. that have established licensure. Some IBCLCs are also nurses and may have an RN license. Most independent IBCLCs are not RNs, and therefore use only the NPI# for insurance claims.
  • When you appeal a claim, make sure to include the superbill, and information about:
    • The reason you sought help, especially mentioning if your pediatrician or another healthcare provider referred you.
    • Anything you were told on the phone by the company.
    • Whether they failed to give you a list of IBCLCs that would be covered.
  • Consider including this information sheet, especially if your company seems unclear about what an IBCLC is:
  • The Surgeon General’s Call to Action to Support Breastfeeding of 2011 lists as Action #11 “Ensure access to services provided by IBCLCs” and specifies that insurance should “Provide reimbursement for IBCLCs independent of their having other professional certification or licensure.” – citing this document may also be helpful.
  • If you feel that your insurance company is not complying with the ACA requirements, or handling your claim appropriately, consider complaining in writing to the State Insurance Commissioner. The contact info for Texas is:

Commissioner of Insurance
PO Box 149104
Austin, Texas 78714-9104
512-463-6169

Street Address:
333 Guadalupe Street
Austin, Texas 78701

Consumer Help Line
1-800-252-3439
512-463-6515 in Austin

Sample Appeal Letter

SAMPLE LETTER:

COVERAGE FOR LACTATION CONSULTANT

Download the Word Document here
To Whom It May Concern:

I am enrolled in a [INSURANCE COMPANY NAME] plan, policy number [POLICY NUMBER]. I recently tried to access lactation counseling that should be covered by my health insurance. The Patient Protection and Affordable Care Act requires insurance coverage of breastfeeding support and supplies with no cost-sharing. However, when I contacted [INSURANCE COMPANY NAME] about the coverage by [SPECIFY METHOD, PHONE] on [DATE], I was told I could not get coverage of [LACTATION COUNSELING] because [SPECIFY REASON, SUCH AS NO IN-NETWORK PROVIDERS].

Under § 1001 of the Patient Protection and Affordable Care Act (ACA), which amends § 2713 of the Public Health Services Act, all non-grandfathered group health plans and health insurance issuers offering group or individual coverage shall provide coverage of certain preventive services for women with no cost-sharing. The list of women’s preventive services that must be covered in plan years starting after Aug. 1, 2012 includes “comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment [] for the duration of breastfeeding” (see attachment).

My health insurance plan is non-grandfathered and the plan year started on [PLAN YEAR DATE]. Thus, the plan must comply with the women’s preventive services provision.

The insurance plan has not established a process for me to obtain in-network lactation counseling, as required by federal law. Federal guidance on the preventive services clarify 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.”

Since [PLAN YEAR DATE], I have spent [TOTAL AMOUNT] out-of-pocket on [LACTATION COUNSELING], despite the fact that it should have been covered during that time. I have attached copies of receipts which document these out-of-pocket expenses. [COMPANY NAME] must rectify this situation by reimbursing me for the out-of-pocket costs I have incurred during the pe­riod it was not covered without cost-sharing. Furthermore, [COMPANY NAME] must ensure breastfeeding support and supplies, including lactation counseling are covered without cost-sharing in the future by changing any corporate policies that do not comply with the Affordable Care Act.

Sincerely,

[YOUR SIGNATURE]

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