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Tips for Requesting a "Gap Exemption" for your Lactation Visit

Insurance carriers make it very difficult for IBCLC's to become in-network Providers. However, you may be able to request "in-network" coverage from your insurance carrier for your lactation visits for a specified number of visits or months. Because I am a licensed Provider (Nurse Practitioner) I can use Provider/medical coding for your visit and you will likely receive partial to full reimbursement. 

Here's how to do it:

  1. Request an order from your Provider or your baby's Provider to see an IBCLC. The order must be for the parent and does not need to be for a specific IBCLC. I do not need this order but you will submit to your insurance company to document medical necessity.

  2. Call your insurance company and request the IBCLC to be granted a "Gap Exemption" to be in-network for your visit. You will explain that there is no covered IBCLC in your area or no other IBCLC in your area that offers the services your are seeking. Start this process as early as you can and reimbursement is not guaranteed.

  3. Your insurance company will ask for some procedure and diagnosis codes. ​​If they say they will not pay for the codes listed, ask which codes they will cover and let me know. See below for codes. 

  4. You will pay for your visit out of pocket and I will provide you with a Superbill with medical codes to submit to insurance. Reimbursement is not guaranteed. Even if I am not approved to be "in-network" for your visits, you can still submit a Superbill and they will likely reimburse you something. 

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CODES TO PROVIDE INSURANCE

If insurance will cover your visit as "preventative visit": 99404 

If insurance will cover your visit as "problem visit": 99205 

Diagnosis (ICD-10 code): Z39.1 - Care and examination of the lactating mother

Estimated number of visits: 4-6

Provider: Jennifer Gerard, APRN, FNP-C, IBCLC

Provider NPI: 1417488255

Provider EIN: 87-4772820

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