Aetna lactation support reimbursement process

In this article we want to run through the specifics of getting reimbursed for Aetna. This is just one example of a plan, so your experience may vary slightly depending on your own individual plan. We have published an article outlining the general steps to figure out the reimbursement process here.  

The usual process

1. Find out if your lactation consultant is in or out of network

Out-of-Network

  • Aetna covers 80% of the allowable amount/recognized amount per telelactation appointment. The allowable amount varies based on your individual plan and is outlined in your benefits plan. This coverage is based on reasonable and customary rates
  • Double check if your plan includes an out of network deductible (you have to pay a certain amount before your insurance kicks in to pay out of network coverage)

In-Network

  • Should be covered 100%

2. Double check which codes you might need from your provider. This is super important because if it is not coded correctly, you may run into trouble with reimbursement. There are multiple codes that could be used depending on your individual plan

3. Attend your appointment

4. Pay with a credit card or FSA/HSA to your lactation consultant (I know, not ideal. It is a similar process as the dentist, which is frustrating)

5. Get the superbill from your lactation consultant

If you have any further questions Aetna recommends contacting provider services for help with billing.

Health insurance terms

Allowable/Recognizable amount: This is a number set by you insurance as the value of the service.  This is also the amount that insurance uses to calculate payment. This amount does not necessarily match the amount that is charged by providers. In the case of out of network coverage, you will have to pay the difference if the provider charge is over the allowable amount. Also Aetna specifically states that while deductible and coinsurance counts towards out-of-network cap, anything owed over the recognized amount does NOT count towards the cap.

Codes: These are an agreed upon set of numbers and letters that physicians and insurers use to label diagnoses and procedures.  

Copay/Coinsurance: The fixed amount of money you must pay out of pocket for a service as defined by your insurance after you have reached your deductible.  (For example say the copay for an office visit is $20 your deductible is $1000 and your bill was $200.  If you’ve already paid your deductible then you only pay $20; if you haven’t you would pay any/all of it to reach the deductible).

Deductible: The amount of money you have to pay before your health insurance begins covering costs. You must pay 100% of costs up to deductible before insurance kicks in.

In-Network: A set of providers that have a contract/relationship with the insurance company. These are usually searchable and identified on your insurers website.

Out-of-Network: Any provider that is not part of the in-network.

Pre-authorization or prior authorization: A process deeming that a service or treatment is medically necessary. It is required before the insurance company will agree to cover certain services, though it is not a guarantee that any/all expense will be covered.  For in-network providers, your doctor will usually seek approval; For out of-network providers, you are responsible for seeking approval.

Superbill: This name always cracks me up. There is nothing super about it, except for the fact that it is an itemized form. It is used by healthcare providers to detail services provided to a patient. It is the main data source for creation of a healthcare claim, which will be submitted to payers for reimbursement.

Andrea Ippolito

Leave a Comment