1. Your health insurance plan may require “prior authorization” before the insurance company agrees to cover (or pay for) certain medical services or equipment.
   
2. Prior authorization means approval by an insurance company before the service is rendered for the member to receive services, medical products (i.e breast pump), tests or surgical procedures.
   
3. Many insurance companies want to know  that the prescribed services are medically necessary. In other words, the insurance company does not want to pay for medical equipment or services that are not really needed.
   
4. The insurance company will make a decision based on information that your healthcare provider (i.e. Pediatrician, PCP, Obstetrician, Midwife, Lactation Consultant) gives to them.

• How to find out if your insurance company requires prior authorization:
  

1. Call the Member Services Department for your insurance.
   
2. The customer service representative will be able to give you the necessary information and tell you whether they require a referral from one of yours or your baby's physicians.
   
3. If you talk with a customer service representative who seems unsure, ask to speak to a supervisor.
4. If your insurance plan requires your doctor or lactation consultant  to call or send a  letter called a “Statement of Medical Necessity” or “Letter of Medical Necessity,” you can call your doctor and/or our office to request a call or letter.
5. This call or letter may also be needed in addition to a written prescription for a breast pump.
6. Even if your insurance company does not require this, it often helps to include a Letter of Medical Necessity from your baby’s physician, your physician or one of our lactation consultants indicating why he/she has prescribed the equipment and services for you or your baby.

•   What to ask your insurance company about prior authorization.

1. "Does my plan require prior authorization for coverage of RNs* or Lactation Consultants or breast pumps? (* Many insurance companies will cover services with an RN but not a lactation consultant, therefore all of our lactation consultants are also RNs.)
2. Do I have to get prior approval for my appointment to see an RN or a lactation consultant?
3. Does my plan require prior authorization for an electric breast pump?

• What is the process for getting prior authorization for RNs or Lactation Consultants or breast pumps?

• In-Network vs Out-of-Network:

1. Does your insurance provider allow you to go out of network?
   
2. In the state of Massachusetts, the insurance companies do not contract with private practice lactation consultants.

• What paperwork or proof do I need to send? We are happy to assist you with this process.
  

• How do I send the necessary information? Fax number?

• How long will it take to hear if it is approved? If they say they are “not sure,” tell them that it is crucial to the success of breastfeeding that you be seen by the RN/Lactation Consultant within 24-36 hours.

• How long is the prior authorization good for or when will the approval time “expire?” 
  

1. How many RN/lactation consultant visits wil be approved?
   
2. If they approve for a breast pump, is there a specific vendor you must use?

• Can you please tell me within the next few hours whether I am approved to see the RN/lactation consultant?

• Do I file the claim with my insurance company for a breastpump and/or lactation services? 

1. We are happy to provide this service for you. We are contracted with a billing service in order to maximize your efforts to get insurance reimbursement.
   
2. During your visit, we will make a copy of your insurance card and obtain the necessary information from you to file a claim.

• Patient’s full name, address & phone number
• Patient’s Social Security number
• Patient’s date of birth and gender
• Policy and group number
• Policy holder’s name, if different from patient
• Policy holder’s relationship to patient

• Do you file after each visit?

1. Typically we batch all of your visits together on one claim and file after your last visit.
   
2. Batching your claims saves us money, as we have to pay for each claim we submit.
3. It is important to know that insurance companies require a claim to be submitted within a specified period of time from the date the medical services were provided (or from when you bought or rented your breast pump). This filing time limit is often one year from the date of service. Claims submitted outside of the required time frame may not be considered for payment. As most issues are resolved in a few weeks, We wil file in atimely manner as you may not be reimbursed at all if your insurance company does not receive the claim within the required time period.

• How long does it take for my insurance company to reimburse me?

1. It typically takes up to four to six weeks for insurance companies to process claims.
2. If payment has not been received within six weeks of submission, you should call your insurance company to check on the status of your claim.
   
3. Call the customer service department for your insurance company.
   

•   When you call your insurance company, have the following information in front of you:

1. Your insurance card with your identification/group number, plan information, etc.
2. Pen and paper to write down the names of customer service representatives and any important information they give, as well as the date/time of your call)
   
3. Dates of service that you saw the lactation consultant and/or received your breast pump/supplies.
4. Type/Name of service or breast pump for which the claim was submitted.
   
5. Name of provider that performed the service or dispensed the breast pump
   
6. Total amount you paid and submitted for reimbursement

• Questions to ask your insurance company representative: 
  
  
  1. I’m calling to check on the status of my claim for date of service, (insert date). What date was the claim received?
  2. Has it been processed yet?
  3.  If not processed yet, ask when can you expect the claim to be processed?
  4.  If claim has been processed, ask what was the covered or allowed amount? What is the amount of reimbursement to be received?
  5.  If claim has been processed, ask when was payment issued and to whom?
  6.  If claim has not been received, ask how long does it take after receiving a claim to have it logged into the system for processing?
  7. When should you call back to check again?
  8. Should you resubmit the claim?

• Often a claim denial can be attributed to errors or incomplete information.
  

1. In these cases,  The New Born Baby will make the necessary corrections, attach additional information about why the equipment/services are needed and then resubmit the claim.
2. Even if everything is done correctly and completely, your insurance company may still deny your request for reimbursement.

• How do I appeal a denial for my claim?

1. An appeal is a written request to your insurance company for further review of a denied claim or service.
2. Call your insurance company and tell them that you wish to appeal a claim that was denied and that you need to know what their appeal process requires.
3. The appeal process will vary from company to company.

• What questions do I ask my insurance company representative?
  

1. Why was the claim denied?
2. Who must initiate the appeal (you or your provider)?
   
3. What do I need to send and to what address?
   
4. How long will it take to process the appeal?

• How to write a Letter of Appeal: 
  

1. In this letter, be sure to include information about the medical reasons why you need to pump breastmilk and/or why you need the services of a lactation consultant.
   
2. This could be if your healthcare provider has indicated that your baby needs breastmilk (benefits of breastmilk, formula allergy) or if your baby has some other special need that requires you to pump your breastmilk.

• A Letter of Medical Necessity:

1.  from your healthcare provider may or may not be required with your appeal. In the Appendix of this guide, there is a sample “Claim Denial Appeal Letter.”
2. Even if not required, a letter from your healthcare provider (baby’s pediatrician/neonatologist or your lactation consultant) can be very helpful in supporting your position (refer to the Appendix).
3. No matter what type of insurance you have, it is your right to appeal a denial.

• Why would my insurance company deny my claim? Aren't they supportive of breastfeeding?
  

1. Sometimes a claim denial is due to specific exclusions or restrictions included in a particular health plan.
   
2. Specific exclusions or restrictions are services or products that are not covered by your health plan.
   
3. If your claim is denied because the service or products are specifically not covered by your health plan, you may need to file a grievance. 
4. As with the appeal processes, the process for filing a grievance will vary from health plan to health plan.
   
5. Be sure to call your health plan’s customer service department to obtain the specific details.
   
6. Calling for the specific details is important when submitting a claim denial appeal or filing a grievance.

As a health plan customer, you have the right to be heard; keep in mind that the insurance company also has the right to approve or deny your request. The following section will give you some tips for communicating with your insurance company and will help you get the most out of your healthcare benefits. It is important to know that appealed claims are typically successful if the appeal letter and documentation includes information that supports the medical need.

• Helpful Hints for Dealing with Your Health Insurance Company

1. You are in charge of your healthcare needs as well as your baby’s.
2. Knowing your insurance benefits and communicating effectively can increase your chances of having your breastfeeding-related equipment and services covered and reimbursed by your insurance.

• Be confident when calling your insurance company. 

1. As a valued customer, you have the right to receive complete information regarding your health benefits.
2. Your insurance company’s customer service representatives are there to assist you.
3. Part of their job includes answering questions to your satisfaction.

• Remember that your ultimate goal is to get coverage for what you and your baby need.

• If you are met with resistance, simply restate your request.

• Don’t give up.

1. Don’t take “No” for an answer.
2. If you have tried discussing your request with your health plan’s customer service representative, but are not satisfied with how your insurance matter was handled, ask to speak to:

  -A Supervisor in the Customer Service Department

-The Manager or Director of Customer Service or Member Services

• Know your benefits. 

1. Health insurance plans can be confusing. However, you are responsible for knowing what benefits you are entitled to under your policy.
2. If you do not fully understand something, ask your insurance representative or your employer’s benefits administrator.

• Keep track of all communications with your insurance company. Be sure to keep detailed, written records of each conversation you have with your insurance company representatives. Record the date the conversation took place, the first and last names of the representative with whom you spoke and make notes regarding any information that was provided to you. Also, remember to keep copies of all written correspondence that has taken place between you and your insurer.

1. Follow up in writing after speaking with a health plan representative on the phone. Keep your correspondence simple and to the point. Include relevant dates, names of representatives with whom you spoke and what they told you. Also, be sure to include your name, policy number and any other identifying information. Do not hesitate to ask for help from your employer’s Human Resources department and your healthcare provider or lactation consultant. In many cases, your employer makes decisions about what will and will not be covered under your health plan. Your employer’s support may result in the approval of your request for coverage. Having your healthcare provider contact your insurance representative can also be helpful since he/she can support the communication that you have had with your insurance company as to why the requested medical products or services are needed for your baby’s overall health.
   
2. Carefully follow the steps outlined by your health plan for requesting prior authorization, submitting claims or filing appeals. Not following these steps may result in a delay in processing or a denial of your request for coverage.
   
3. Advocate at all levels. Write to your state health insurance commissioner (see Appendix for Directory of Insurance Commissioners, beginning on page 34) and/or your state and Federally-elected representatives and enlist their help by informing them of your health needs and what has occurred with your health plan insurance claims. Notify your insurance company that you have requested help from the state health insurance commission and other agency representatives in resolving difficulties in meeting your healthcare needs.
   
4. Be persistent! Remember that a denial is not necessarily the final word. Ask your insurance company to reconsider their decision and follow-up to make sure they are taking action.
   
5. You can make a difference! Medical directors at insurance companies have indicated that they would be more likely to expand coverage for breastpumps and lactation consultant services if their customers were actually requesting coverage. Enclosed in this guide are several helpful letters (see Appendix, pages 26-37) that can be used to initiate prior authorization or to notify your insurance company of the medical necessity for breastfeeding-related supplies and services. Two of the letters are claim denial letters (one from you and one from your healthcare provider to your insurance company). The prior authorization letter can be used to request coverage for your breastpump/supplies before you make the purchase or rental. The other sample letters are useful to send to your employer and your state insurance commissioner/representative to inform them of the need for this important healthcare benefit. Remember that expression, “the squeaky wheel gets the grease.” The more you make the needs of you and your baby known, the more likely you will get those needs met!