Anthem Lactation Coverage

Securing Insurance coverage for lactation Care

TIPS FOR GETTING REIMBURSED BY ANTHEM FOR LACTATION CARE 
From Serena Meyer of Bay Area Breastfeeding Support

If you are having problems breastfeeding did you know that your insurance HAS to pay for lactation care? Its mandated coverage as preventive health care and you are entitled to it. 

Certain insurance covers certain codes but they all have to cover part of it. 

1.) Call Anthem’s member phone number and ask for a list of in-network lactation consultants in your area. They may give you the run-around or turn it around on you and ask YOU to provide THEM the names of the consultants you want to see -- only to tell you that those consultants are not in-network. If they do this, insist again that they provide a list of in-network lactation consultants. If they try to give you the run-around again, insist yet again that they provide a list of in-network lactation consultants and, if they can't, make sure they clearly tell you that they can't. 

2.) If they can't provide you a list of in-network lactation consultants within a 75-mile radius of where you live, you are entitled to open an in-for-out case. This allows you to get your out-of-network claims processed at the in-network level, so you would only be responsible for the total beyond the in-network total allowed. These cases are handled by a nurse case manager on your insurance company's medical management team. You call the same member phone number but you choose the option for pre-approval or pre-certification and ask to make an in-for-out request. 

3.) WARNING: The wait for this particular team is LONG. It can be over an hour before someone picks up. So when you call, be ready with all of the information you need because you don't want to waste your time. You'll need: the CPT/procedure and diagnosis codes that would be used during your visits; your phone number; your full name and date of birth; your baby's name and date of birth; your home address; how many visits you are seeking and which codes your consultant will use for each visit; your consultant's name; your consultant's business's name; your consultant's NPI number; and your consultant's EIN number. You may also need to tell them whether the visits will be at your home or at your consultant's office. IMPORTANT: Make sure the person opens your case in YOUR name and not your baby's. Also make sure the case includes a date range that will cover ALL of your visits. The representative will give you a reference case number and a fax number that your consultant will use to send what they call a clinical. 

Here is the info they will ask you for: CPT codes: 
99204 for an initial consult and 99404 for preventive health teaching at the same time 99214 for a follow up and 99404 for preventive health teaching at the same time 
ICD10 code: Z39.1, care of the lactating mother Modifier codes: 33 and 25 
Serena Meyer RN IBCLC
Business Name Bay Area Breastfeeding Support 
NPI 1306113881 
EIN 45-3915267 
CA RN license 95048954 
IBCLC number 1113721 
Phone number 925-257-4023 
Fax number 510- 275-0331  
Email [email protected] 

4.) As soon as you have the reference case number, ask your consultant to send a “clinical” to your insurance company with your reference case number on the cover letter. Nothing else should be on the cover letter, especially no personal health information. The clinical should outline what your plan for treatment is. The nurse reviewing your case will use the clinical to make a determination. 

5.) The nurse has 15 calendar days from the time a clinical is received to respond to you. They'll likely call with a determination, but they'll follow up with a letter. In my experience, calling every day to check in on the case doesn't help or speed up the time of a response. 

6.) Once you've been approved, schedule your visits. You'll need to pay for the visits up front. Before your visits, ask your insurance company which claim form you must submit for reimbursement. Print out the claim form and bring it to your visit so you and your consultant can fill it out together. Submit your claim form to request reimbursement as soon as your visit is over. Your insurance company may allow you to submit it electronically via a member portal. That will save you the time of sending it via snail mail. 

Other tips: Write down the name of EVERY person you speak to about your case. That way, there is always a trail and someone held accountable. This will come in handy countless times, I PROMISE. Keep track of every conversation you have related to your case and document exactly what was said and what information you provided during each one. Lastly, be aggressive and don't give up -- because that's what they're hoping you'll do. It's not nearly as difficult as it sounds to track down all the information you need. It just sounds difficult because of the alphabet soup they drown you in. Keep your head up and persevere!! 


Additional resources: 
California Network Adequacy standards:
https://www.dhcs.ca.gov/formsandpubs/Documents/FinalRuleNAFinalProposal.pdf 
Anthem CA Member Claim Form: https://www.anthem.com/docs/24066CAMENABC.pdf 
National Women’s Law Center Toolkit New Benefits for Breastfeeding Moms: Facts and Tools to
Understand Your Coverage under the Health Care LawF

Sample appeal letter for lactation coverage on page 11.
https://www.nwlc.org/sites/default/files/pdfs/final_nwlcbreastfeedingtoolkit2014_edit.pdf?fbclid=I wAR0eRLpFAbeJUaSJwaiOvz9Npg8Y8suTIMTsKjzkqQFA2zUAAaffeQhoLjg 

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