Policies for Clients with BCBS Insurance

We have IBCLCs who are in-network providers for most BCBS plans, except for marketplace plans and Medicaid plans.* To verify that we are in-network with your specific BCBS 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.

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

*Please note that while we are listed as an in network provider for TRS Activecare, these plans limit lactation services to only MD, Nurse Practitioner and Midwives, so they will not cover our services.

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.

Please read this document from Aetna explaining the difference between an in network and an out of network provider.

If either patient (lactating parent or baby) does not have coverage through BCBS or another insurance we are in network with, you will be charged a fee per non-covered patient for each standard visit

Due to insurance reimbursement rates, we bill your insurance for both the lactating parent and baby(ies) at each visit. For those patients who do not have in network insurance coverage for either the lactating parent or the baby you will be responsible for paying a non-covered patient fee.    A superbill can be provided for submission to the other insurance company for reimbursement purposes.

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

Usually, office and virtual visit 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.

We are seeing BCBS apply the full billed amount for in home visits to patient responsibility.

Please contact BCBS 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: 99345/99350, s9443 and 99404
• Office visit codes S9443 and 99404.
• Virtual Visit Codes: s9443 and 99404

Understanding co-pays, co-insurance and deductibles

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

Some BCBS plans restrict coverage for lactation services to only MDs, Nurse Practitioners and Midwives.    In addition, some plans are grandfathered and do not fall under the ACA guidelines.   If you are in one of these plans, your lactation visit may not be covered by BCBS. 

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

Currently, we are aware that all HMO plans 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 BCBS 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.

There are some fees that are not covered by BCBS, 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 will be charged to your credit card following your visit.  This fee is NOT billed or covered by insurance.

We are in network with several other insurance companies including:

• Aetna
• United HealthCare
• Sana Health
• We can not guarantee that your insurance provider will cover our services.

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 
• Home Visit Trip / Convenience fee 
• Co-Pay, co-insurance, deductibles or services that are not covered or denied. 
• Non-covered services
• Fees for non-covered patient