We understand that dealing with insurance companies regarding your infertility coverage might be a little intimidating at first glance. But in order for you to make informed decisions about your infertility diagnostic testing and treatment, you must gather information on your insurance benefits.
To verify insurance benefits by phone, please refer to the customer service phone number printed on your insurance card.
Before you call your insurance company, review the health insurance benefit booklet provided by your employer, and copy any sections that pertain to infertility benefits as well as any benefit exclusions. Our financial staff will be happy to review the document with you in order to assist you in interpreting your coverage.
Specifically ask for benefits relating to infertility. A list of Billing Codes for Infertility Diagnosis and Treatment is provided with this document for your convenience.You should provide both the diagnosis code (ICD-10 code) and the procedure code (CPT code) when requesting verification of coverage. Some procedure codes that typically are covered may be denied if the diagnosis is infertility. This is important!
- Simply having insurance benefit does not mean you are eligible to be reimbursed for the benefit. Ask if there are any specific medical criteria that must be met in order to be eligible for infertility benefits, e.g. Must you undergo lesser treatments (IUI) before proceeding to advanced treatments (IVF/ICSI)? Must you have a specific documented diagnosis?Will IVF/ICSI only be paid for certain diagnoses? Is there any limit, dollar or number, on treatment cycles? Are there any factors that would cause denial of benefits, e.g. prior failed treatment, prior sterilization, etc.?
- Document the name of the customer service representative giving you the information, the department in which he/she works, and the phone number you called. Also ask for a reference number for the phone call.
- Always document the date and time of the phone call as well as what was discussed. Your insurance company also will be documenting the content of the call, so be accurate and comprehensive with your own documentation.Repeat the information you are given to be sure you are accurate.
- If possible, request written confirmation of any benefits described and ask how long it will take to receive this confirmation. If your insurance company advises you to submit a request for predetermination of benefits, ask for the address and fax number where you can send your written request for benefit verification. Be advised that your insurance company may take up to 6 weeks to respond to your request, and the response you receive still may be vague. If your insurance is provided through an employer, you may need to contact your Human Resources department to assist you further in defining your insurance benefits.
- Some insurance companies may require a letter of medical necessity for predetermination of benefits prior to services being rendered in order for your benefits to be paid. Make sure you obtain the address and fax number where this letter must be sent, and ask how long it will take for a response. Keep in mind that any response to such a letter still will not be a guarantee of payment. Your insurance company always reserves its right to deny payment until after an insurance claim is submitted and reviewed.