Policies for clients with Aetna Insurance

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Policy Overview

We will submit a claim for your lactation services with Aetna, and we will attempt to pre-verify your benefits, but we do not guarantee coverage or benefits.

You are responsible for knowing and confirming your own lactation benefits, and confirming that we are an in network provider on your specific plan.

If your policy applies a co-pay, co-insurance or deductible, you will be responsible for paying for these charges.  We are legally obligated to bill you for these charges.

Some Aetna plans require a referral or precertification, and we recommend checking with Aetna to see if this applies to your plan.

If our claim is denied by Aetna because the services require a referral or precertification, and the referral or precertification was not obtained prior to your visit, you will be responsible for paying for these services out of pocket, but we can offer a timely payment discount.

If our services are not covered by Aetna, you will be responsible for paying for them out of pocket, but we can offer a timely payment discount.

Is Bayou City Breastfeeding an in-network provider?

We have IBCLCs who are in-network providers for most Aetna plans, except for Kelsey-Seybold and  Hermann Memorial Restricted acccess networks. To verify that we are in-network with your specific Aetna plan, please login to your Aetna account and search for “Lactation Consultants” in the "Find A Doc" section of the website. Please be aware that you may need to expand the mileage to a 50-mile radius. to find us.

To find out your specific benefits, please contact Aetna directly.

What if my baby is not on my Aetna plan?

If the baby does not have coverage through Aetna, you will be charged a $40 fee for the baby per standard visit

Due to insurance reimbursement rates, we bill Aetna for both mom and baby(ies) at each visit. For those patients who do not have Aetna coverage for baby will be responsible for paying a $40 per non-covered patient fee.  We do not directly bill other insurance carriers, and therefore, this fee is paid out of pocket.   A superbill can be provided for submission to the other insurance company for reimbursement purposes.

Will I have a co-pay, co-insurance or deductible to pay?

If your policy applies a co-pay, co-insurance or deductible, you will be responsible for paying for these charges.

Usually, services are covered at 100% under the mother, but sometimes there is a deductible, co-pay or co-insurance. These charges most commonly apply to baby; however, they may occur on mom in some plans.

Please contact Aetna to find out if your services will be subject to a deductible, copay or coinsurance. When speaking with them, you can reference the codes we use for our services.

  • Home visit codes: 99344/99349, s9443 and 99404
  • Office visit codes : 99203/99213, s9443 and 99404.

Understanding co-pays, co-insurance and deductibles

Are there any coverage restrictions on Lactation services?

If our services are not covered by Aetna, you will be responsible for paying for them out of pocket, but we can offer a timely payment discount.

Some Aetna plans restrict coverage for lactation services. Examples of these plans include grandfathered plans and restricted access plans (such as Kelsey-Seybold or Hermann Memorial). If you are in one of these plans, your lactation visit may not be covered by Aetna. 

Do I need a referral or precertification?

 Some Aetna plans require a referral or precertification, and we recommend checking with Aetna to see if this applies to your plan.

Currently, we are aware that HMO plans, grandfathered plans (*such as Exxon, Huntsman International, Boon Chapman and Rice University*), selected Meritan plans and the Aexcel Plus Aetna Select plan require referrals.

If you are in one of these plans, you need to get a referral from your PCP and the baby’s PCP prior to your first visit or the services may not be covered.

If our claim is denied by Aetna because the services require a referral or pre-certification, and the referral or pre-certification was not obtained prior to your visit, you will be responsible for paying for these services out of pocket, but we can offer a timely payment discount.

Are there any other fees or charges I may have for the visit?

There are some fees that are not covered by Aetna, regardless of your plan.  If we know that a fee will not be covered, these fees will be billed to the patient.  Examples of non-covered services include the Home Visit Trip/Convenience Fee or a late cancellation or no-show fee.

If you have chosen to have a home visit, our standard trip fee/convenience surcharge of $60 will be charged to your credit card following your visit.  This fee is NOT billed or covered by insurance.

What about other insurance companies?

We are an out of network provider for all other insurance companies.

  • We do not bill any other insurance carriers for lactation services.
  • We will provide you with a super-bill, upon request, for you to file with your insurance provider to request reimbursement.
  • We do partner with Better, which is a service that can file your claim for you. for more information about Better, please visit their website or download their app.
  • We can not guarantee that your insurance provider will cover our services.
Credit Card Authorization

We require that all patients provide a credit card prior to the initial visit.  We will not schedule your appointment without having a credit card on file

  • You are authorizing us to save your card in your file and use it to pay the following fees:
  • Late cancellation or no-show fees ($50 per occurrence)
  • Home Visit Trip / Convenience fee ($60 per visit)
  • Co-Pay, co-insurance, deductibles or services that are not covered or denied. (up to a maximum of $195 per visit, if paid within the *Timely Payment Discount* period)
  • Non-covered services (fees will vary)
  • Fee for non-Aetna patient ($40 per patient)