Apply for a GAP exception:
- 1. Determine if you have a grandfathered plan. If your plan is grandfathered 1) you would have received notification and 2) you will not have lactation coverage.
- If your insurance carrier does not have any IBCLCs in network and they will only cover services with in-network providers, you have a right to ask for an out of network exemption (or gap exemption). It is helpful to ask for an exemption for several visits since most cases require 2-4 visits and more complex cases can require 6 visits. Here is the information you need from me to get pre-approval:
Provider Name: Lactation Consultants of Atlanta
NPI # 1144627746
EIN # 58-2052409
Address: 2141 Kingston Court SE Suite 103 Marietta, GA 30067
Diagnosis Code: Z39.1
Procedural Codes (different MODIFIER + PLACE OF SERVICE if home or tele-health)
99404 & S9443
Modifier: GT for Telehealth
Place of Service: Office- 11 Home -12 Telehealth-02
You will want to keep a written note with the date, time and NAME of the supervisor or agent who you spoke with. Ask them to make a record in your file and to send you a confirmation of the conversation and the information they gave you regarding the coverage under your benefits.
- If you have an employer-sponsored plan, you may have a benefits administrator who can advocate on your behalf with the insurance company.
- It can be useful to get a referral from your pediatrician and or your OB for lactation support, though it is not legally required. If you get a referral mention this when speaking with your insurance carrier.
- POSSIBLE SCRIPT TO USE WHEN CALLING: If you have a referral from your pediatrician make sure to mention this.
**Once you are able to get the GAP exception, let us know. We will schedule you a consult, however payment will be due at the time of your appointment. After your consult, we will provide you with a superbill. You will need to submit the superbill to your insurance company along with the GAP exception confirmation to help the reimbursement process from your insurance company run smoothly.
If you have any other questions, please let us know. We are looking forward to helping you reach your breastfeeding goals.