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 find out specifics of your coverage.  As solo practitioners, IBCLCs generally do not bill insurance directly, but 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.

1. Since independent IBCLCs are usually out-of-network, it’s best to 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) A National Provider Identification (NPI) number and tax ID (EIN) number.
b) A code for the type of appointment (CPT code), such as a home visit.
c) A code for the problem (ICD-9 code), such as slow weight gain in newborn.
d) The amount you paid.
e) The date of service.
f) 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.

1. 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.

2. 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, since this is not meaningful coverage. (See this information about appeals.)

3. Some insurance companies are still unfamiliar with the IBCLC credential. They may ask for a copy of your provider’s state license – this is not possible, since IBCLCs are board certified, not state licensed. (As of 3/1/13, no US state has a licensing program for IBCLCs.). Some IBCLCs are also nurses, and as such can provide a RN license, but most independent IBCLCs are not RNs, and therefore use only the NPI# for insurance claims.

4. When you appeal a claim, make sure to include the superbill, and information about:

a) The reason you sought help, especially mentioning if your pediatrician or another
healthcare provider referred you.

b) Anything you were told on the phone by the company.

c) If they failed to give you a list of IBCLCs that would be covered.

5. Consider including this information sheet, especially if your company seems unclear about what an IBCLC is:

6. 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.

7. See this information about appealing claims under the ACA, including the right to request external review. http://www.healthcare.gov/law/features/rights/appealing-decisions/

8. 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 :

Cassie Brown
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

Link to file a complaint

A form for filing a complaint is here