The Archives are a wealth of information and experience on this topic.

I posted on Jan 15, 1997, Subject: BFing and Insurance Reimbursement (so
anyone can find it easily) which touched on some points about
reimbursement including using the appeals process from insurance. The
.02 version follows in this posting.

My January post is a summary of the articles I wrote for Medela Round-Up
(references are given in the Jan LactNet Posting). My information was
based on the time when I was employed as the Maternal-Child Case Manager
for Blue Cross of California. HMOs and the appeal process work pretty
much the same today.

The basic things to remember, as with anything a client wants
reimbursed, are:

1. Have a *medical* diagnosis (ie, the diagnosis requiring
surgery)(also, remember that "premature" or "SGA" or "return to work"
are NOT medical diagnoses!! "NEC" is!)

2. The prescription has to fit the patient (ie, if the baby is having
surgery, then the Rx is written for a pump with BABY's name on the Rx)

3. The patient's physician signs the Rx (See # 2, and have Peds sign it,
or the surgeon)

4. The insurance is submitted under the name of the patient with the
diagnosis (ie, the baby who is having the surgery)

#2 and #4 were the *most common* reasons for denial at Blue Cross - at
least 80%. The mother's name was on the Rx and the baby's name was on
the insurance form with the diagnosis. Sorry, folks, but no insurance is
going to provide money for a client (mom) without an active diagnosis,
or the diagnosis of a different client (baby)!! Think about it - if you
needed crutches for a sprained ankle, would you be angry that the
crutches were denied because you submitted a form with your husband's or
son's name on it? No, of course not.

I don't know if this was the problem of the current discussion -
hopefully not - but do keep in mind, especially if time is of the
essence, that there is usually a case manager somewhere within the
insurance. The client can ask for review and contact with them - at
least it is a real person, and usually an RN if not a BSN (can interpret
studies).

Good luck! Keep raising those consciences!!!

Katharine West, BSN, MPH
Sherman Oaks, CA