Policies for Clients with BlueCross BlueShield Anthem PPO Insurance

Bayou City Breastfeeding is not in network as a group. We are in network as individual providers. When talking to BCBS to check your coverage, you will need to give them the name(s) or the specific provider(s) you would like to see. 

**We do not accept marketplace and HMO plans**

To verify that we are in network with your specific plan, please login to your BCBS 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.

An in-network provider has a contract with your insurance company and agrees to provide services at a contracted rate, which is usually discounted.  An out of network provider does not have a contract with your insurance company and may charge any rate for their services.  Some plans cover out of network providers and other require you to see an in-network provider.

If we can't bill an insurer for either the parent or baby, you’ll need to pay a non-covered patient fee: $80 for the parent and $60 for the baby.  

If we can bill insurance for both patients,  you might also pay extra if the plan:

• Doesn't cover lactation visits billed to the baby's plan.
• Puts a cap on the number of visits and you've used them all up for either the baby or the parent.
• Adds copays, coinsurance, or deductibles to the baby’s claim.

BCBS has been changing their policies related to the way we can bill and severely limiting us. Right now we're not expecting any out-of-pocket but please be prepared to pay up to $60 on each infant claim. There also may be copay/coinsurance/ deductible applied to moms claims. In the event any amount is applied to moms claim, we do request reprocessing and appeal if we cannot get it corrected. In the event that does not work, On a postpartum visit, it depends on whether they process baby’s claim correctly. Occasionally (about 10-20% of the time with UTS plans), we will see BCBS apply out of pocket with your plan. If they do, we appeal it and only charge you if we cannot get it corrected. The max out of pocket for baby would be around $77 for an initial visit and $60 for any follow ups.

We will not charge anything until the claim has come back and you have been notified. Full payment policy and processes can be found here:https://bayoucitybreastfeeding.com/bayou-city-breastfeeding-payment-policy/

If your ID begins with the following prefixes, BCBS has recently implemented policy changes that severely restrict the billing codes for lactation services. These changes have dramatically reduced the reimbursement rates to a level that is not sustainable for our practice without compromising our quality of care.

As a result, and with sincere regret, we must inform you that we can no longer accept BCBS Plans with member IDs beginning in  T2U, TRS or T2G effective immediately.

This decision was forced by the new limitations set by BCBS, not by our desire to serve you less. 

BCBS Home Visits: BCBS applies the entire billed amount of the home visit codes to patient responsibility. If you choose to use your BCBS insurance for a home visit be aware they apply the entire amount to patient responsibility and this amount is $375 ($425 twins). You can expect BCBS to apply to patient responsibility and we will bill this amount to the card on file for each home visit. Our discounted self pay rate is significantly less at $295 with travel fee included. If you would rather be self pay for your home visit we will send you our self pay election form for your signature.

BCBS of Texas customers should expect to have $60 per visit OOP on their baby's claim.

BCBS PPO plans do not require referrals for our services however we kindly ask you to call BCBS and ask the following questions to ensure your understanding of your benefits. 

1. Is your plan grandfathered (Non ACA compliant)? 
2. Does your plan have lactation benefits? 
3. Does your plan limit lactation coverage to physicians, nurse practitioners, and midwives? 

**If any of these circumstances apply to your claims and they are denied for coverage, you will be billed at our discounted cash pay rate**

We require that all patients have a valid card on file to secure the booking of their initial visit. We will not schedule your appointment without having a valid card on file. 

* You are authorizing us to save the card on file and use it to process the following fees: 

• Late cancellation / no show fees
• Home Visit Travel Fee
• Copay/ Coinsurance / Deductible
• Non covered / denied services
• Non covered patient fee for mom or baby who does not have billable insurance