Out-of-Network Gap Exemption
Under the Affordable Care Act, most insurance companies are required to cover preventative lactation services without additional cost or copay. Unfortunately, many insurance companies do not have enough (or any) lactation providers in their network to provide these services.
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If you have called your insurance company and they do not have any IBCLC’s in-network, they must cover the services from an out-of-network provider without cost-sharing. This is called an Out-of-Network (or “Gap”) Exemption.
You can contact your insurance company to request a gap exemption.
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They will usually have you complete a written request and can provide you with the form.
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From your referring in-network provider you will likely need to obtain: a Letter of Medical Necessity with appropriate diagnostic codes, Referral for lactation services and clinical notes/visit history.
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Write down who you talk to and the specific things they will require. They may only cover certain codes so please write these down.
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You will need the following information from us:
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Practice name: J Gerard Nurse Practitioner PLLC
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Provider: Jennifer Gerard, APRN, FNP, IBCLC
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Address: 8595 Pelham Rd, Ste 400, #536 Greenville, SC 29651
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Phone: 864-309-0223
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Fax: 864-305-3498
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Tax ID: 874772820
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NPI: 1417488255
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Diagnosis codes: Z39.1, P 92, P 92.9, O92.4
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CPT codes: s9443, 99403, 99404, 99203-99205, 99213-99215
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For more information on understanding your coverage from the National Women’s Law Center (including sample script and appeal letters) click here.