Aetna Insurance Procedures

 
 

For Aetna, I’ve had good success with coverage in full, often fairly quickly. Sometimes it does take many phone calls from you to them but almost all my clients that decide to pursue coverage have received it (especially when pre-certification is done and they are willing to make some phone calls). Most get 100% coverage, some have gotten 70% (it depends on the specific plan) with no co-pay or deductible. Here is the process that seems to work best:

  1. Call the Pre certification Line at 1-800-333-4432 as soon as you are able (before our visit, the day after our visit, or a few days after depending on timing of everything). You can also call to get pre-certification before you baby is born, which is one less thing to do later. Remember that if you call on a day *after* our first visit, you will need to have them backdate the approval to the date of our first visit to get coverage. I cannot backdate your claim.

  2. Tell them there is no IBCLC that is in network with Aetna within 60 miles of Syracuse (this is true as of Sept 2020, but they may want to verify this) and you want gap coverage to see an IBCLC who is out of network (OON). My information and all necessary numbers are at the bottom of this list. It is likely that I am still listed under my old business name- Bluebird Birth & Breastfeeding, and not under Syracuse Lactation. [This has been updated as of summer 2021 so it should no longer be an issue, but you will be my first that tries after they updated my system so lmk if they are a pain about this].

  3. Tell them you want an expedited request because you are having breastfeeding issues (or for a prenatal, anticipate having breastfeeding issues). This is helpful if we have already met in order to process your claims quickly, or to get everything in order before we meet if you need to have verification that you definitely have coverage to see me. (Please remember if for any reason they do not pay your claim, you would be self pay and payment is due in full at the time of your visit). The expedited request should take the processing time from 14 business days to under 72 hours (and sometimes sooner- keep an eye on your account/call them back for updates). It is important that you let me know the pre-certification number as soon as they give it to you so I can have my biller submit your claim.

  4. Be sure to ask for coverage for the full 6 visits (most plans cover 6 visits), and try to make it for one full year ( from the date of our first visit) if possible. Often breastfeeding or bottle feeding (or starting solids, etc) related things come up later on and I can help with lots of things throughout the year if needed/you have coverage.

***Ask if one of the 6 visits covered is for a prenatal visit****

***Also ask if your visits will be covered if they are video/telehealth. I'm not sure if they are still covering telehealth but even regardless of travel, covid has meant more telehealth visits so we can keep things moving. You might have to really work at this one....and if they won't cover telehealth for you - which should be listed on your pre cert paperwork when you get it!- and you want to keep pursuing this, lmk.***

  • While I’m happy to use whatever appropriate lactation codes that I normally use or that they want me to use, they will often not tell you what they want me to use- but ask anyway! If they tell you, that is super helpful information. If not, they most often like these CPT codes: 

99404

S9443

99342

Be sure to ask what codes they want for initial visit, follow up visit, and if needed for a prenatal visit (S9443 should be the only possible code for a prenatal visit).

I have always used Z39.1 for an ICD 10 code, so they should be fine with that if they ask. O92.70 is an alternative that I can use as well (the first digit is the letter O, the last is the number 0).

Let me know what CPT code to use for which type of visit.

  1. I do not correspond directly with any insurance company, including Aetna. This includes any pre-certification paperwork. In the past my clients have gotten full coverage without me doing any additional paperwork other than my biller submitting the claim (see #7). This includes faxing them notes or justification for the visits. Tell them you are seeing an IBCLC because you are having breastfeeding issues and that is the justification. If they insist that pre-certification paperwork needs to be completed by me, please let me know.

  2. You will need to submit the superbills I give you after I process your payment (after each appt) to get your reimbursement. So ask them for a claim form and if there is anything else you need to do to submit other than fill out the claim form and include the superbill from me (which will have all the important info).

TLDR: Call the pre-certification number to get an expedited request for coverage for me as an out of network provider for 6 visits for as many months as they will allow. Also get the CPT code they want me to use for the initial/follow up visits.

Let me know the pre-certification number and the CPT codes to use and I will give you a superbill to submit. I do not correspond directly with any insurance companies.

Info you may need when you call:

Jen Deshaies, IBCLC

Syracuse Lactation

License# L-60471

NPI# 1639543432

Tax ID# /EIN# 81-3763360

Phone (315) 263-7558

Fax (315) 748-5363

Mailing Address:

8235 Sixty Road

Baldwinsville, NY 13027

Sometimes my old business name is listed instead:

Bluebird Birth & Breastfeeding

And sometimes my office address is listed instead:

Willow Health & Wellness

3090 Belgium Rd, Baldwinsville, NY 13027

My new office address (as of March 2022) is:

7000 East Genesee Street Building C Upper Level Fayetteville, NY 13066