Breastfeeding Support & Breast Pump Benefit Description The Alliance is committed to supporting breastfeeding for our members. The American Academy of Pediatrics recommends breastfeeding through the first year of life, when possible. Please see the following pages for Alliance breastfeeding benefits and billing information. The listed services and equipment may be billed under either a mother or baby who is a current Alliance member. Billing limits apply to the mother/baby unit. • • • • •
Lactation Consultant Visits Home Health Nurse Visits Breast Pumps & Supplies Other Breastfeeding Resources List of Approved Lactation Consultants
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For more information about this benefit, contact the Senior Health Educator at (831) 430-5570.
Lactation Consultant Visits (consultant must be an IBCLC and pre-approved by the Alliance) Lactation Consultant Visit
• Restricted to Alliance-approved providers (see
page 4 for list). • Provided by an International Board-Certified Lactation Consultant (IBCLC). • Addresses complex problems, such as mastitis, suppressed lactation, etc. • IBCLC does not need a Medi-Cal provider # to bill. Invoice or bill on CMS1500 or UB04 claim form (available at office supply stores).
No RAF or TAR required for 4 units per 12 month period for a total of two hours. Referred by doctor, mid-level, certified nurse midwife, Alliance case management, or self referral.
CPT: Z5023* ICD-9 (Choose appropriate code: 675.00–676.94, 779.31-779.34, 783.3) Reimbursed at $25 per 30-minute unit. Limited to 2 30-minute units per visit.
Home Health Agency Nurse Visits (agency must have a Medi-Cal billing number) Initial nurse home visit, Postpartum
Follow-up nurse home visit for identified breastfeeding problems
• Restricted to home health agencies only. • For all births covered by the Alliance, mother
may receive an initial nurse home visit after delivery. • Provided by a trained home visit nurse. • Addresses common problems. • Restricted to home health agencies only. • For mothers who have never breastfed and
mothers who want to breastfeed but were previously unable to nurse longer than one month. • Addresses common problems. • Provided by a trained home visit nurse (must be billed through an agency that has a Medi-Cal billing number).
No RAF or TAR required for 1 visit per 12 month period. Hospital or physician notifies home visit agency for initial visit.
CPT: Z6900 or Z6920
No RAF or TAR required for 1 visit per 12 month period. Home visit
nurse will order at initial home visit, if needed.
* Alliance-only codes. Do not use with other insurers or with fee-for-service Medi-Cal. Alliance Breastfeeding Support and Breast Pump Benefits - Page 1 of 4
ICD-9: V24.2 Routine postpartum care Standard Reimbursement Limited to one visit.
ICD-9: V24.1 Lactating mother, supervision of lactation. Reimbursed at $80.
Breast Pumps - Purchase, Rental & Supplies (reimbursement to contracted pharmacies, contracted medical supply vendors, or approved lactation consultants only) Personal Use Electric Breast Pump PURCHASE
• For mothers separated from baby, certain
medical conditions of baby, or if mother is returning to work or school. NOTE: • Claims follow “By Report” requirements.
Attach pricing/catalog page.
Hospital Grade Electric Breast Pump DAILY RENTAL
Per Alliance policy 404-1606 Provision of Breastfeeding-Related Durable Medical Equipment (DME), daily rental of a Hospital Grade Breast Pump will be covered when medically necessary. These conditions include, but are not limited to: • Mother continues to be treated for
postpartum complications that preclude direct nursing at the breast. • Mother has a medical condition that requires treatment of her breast milk before infant feeding. • Mother is receiving chemotherapy or other therapy with pharmaceutical agents that render her breast milk unsuitable for infant feeding. • Infant continues in hospital after mother is discharged. • Infant has congenital dysfunction or neonatal condition that precludes effective direct nursing at the breast (physician should refer infant to California Children’s Services). • Personal kit for use with rented hospital Kit for grade pump, per requirements above. Hospital Grade • May also be ordered for use with a multiPump or user pump borrowed from WIC. Manual Breast Pump PURCHASE
No Referral or Authorization Request required. Ordered by physician, midlevel, certified nurse midwife, or IBCLC.
CPT: E0603 Modifier: NU Reimbursed at 80% of MSRP up to a maximum of $250.00. ICD-9: V24.1 or other appropriate code.
Authorization Request required only if rental is to continue beyond 60 days.
CPT: E0604 Modifier: RR
Authorization Request must include documentation of medical need, infant’s date of birth, and requested duration of rental.
ICD-9: V24.1 or other appropriate code.
Approved Authorization Requests will specify a time limit based on medical condition. Ordered by physician, midlevel, certified nurse midwife, or IBCLC. No Referral or Authorization Request required. Ordered by physician, midlevel, midwife, or IBCLC.
Reimbursed at $2.72 per day (incl. tax).
May be billed in conjunction with E0602 (see below). When previously paid rental charges equal the documented retail purchase price of the rented item, the item is considered to have been purchased and no further reimbursement to the provider will be made [per Title 22. Section 51321(C)].
CPT: E0602** Modifier: NU Reimbursed at retail rate plus tax if pricing attached, or at estimated amount if no pricing sent. Kit may be billed in conjunction with E0604.
**Per Medi-Cal Manual, E0602 may be used to bill either a manual breast pump or a breast pump kit.
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Breast Pumps - Purchase, Rental & Supplies (reimbursement to contracted pharmacies, contracted medical supply vendors, or approved lactation consultants only) Misc. Medical Supplies for Lactation Management and Support PURCHASE
• Includes nipple shields and creams. • Does not include furniture, pillows or bedding.
Call the Alliance Claims Department for item-specific clarification: (831) 430-5503 Monday – Friday, 9:00 a.m. – 4:00 p.m.
Prescribed by doctor, mid-level or midwife.
CPT: A9900 Modifier: NU
No Referral or Authorization Request required.
ICD-9: V24.1 or other appropriate code. Reimbursed at retail plus tax if pricing attached, or at estimated amount if no pricing sent.
Other Resources Available to Alliance Members (Bilingual English/Spanish) Service
How to Access
Alliance Health Education Dept.
Alliance Health Education Coordinators can provide easy to read health education materials, referral information, and help accessing services.
Members or providers can call 430-5580 or 1-800-700-3874 x5580
No charge to members or providers.
Breastfeeding Helpline (U.S. Dept of Health & Human Services)
La Leche League-trained Peer Counselors offer support for successful breastfeeding. Counselors can help with common breastfeeding questions on issues ranging from latching to pumping and storage.
No charge to the public.
Comprehensive Perinatal Services Program (CPSP) Breastfeeding Services (MediCal Members Only)
• Approved Comprehensive Perinatal Services Program (CPSP) providers offer breastfeeding education, nutritional education, support and referrals for Medi-Cal members only.
County Perinatal Services Coordinators:
Women, Infants and Children (WIC) Program Breastfeeding Services
• WIC serves pregnant or breastfeeding women, and children up to age 5. • Alliance Medi-Cal members automatically qualify for WIC. Other members may qualify, depending on income. • WIC provides breastfeeding classes during/after pregnancy and other support services (including breast pump loans and counseling). • Women get more WIC benefits if breastfeeding.
• Services are provided in the antepartum and postpartum period. • Services are billed with specific CPSP codes. Providers must be set up in the Alliance system as CPSP providers in order to be reimbursed for these codes.
TDD: 1-888-220-5446 (www.womenshealth.gov)
Santa Cruz County 831-454-5477 Monterey County 831-755-4640 Merced County 209-381-1142
Mothers should call WIC directly for enrollment information: Santa Cruz County 831-426-3911 (Santa Cruz) 831-722-7121 (Watsonville) Monterey County 831-393-3251 (Seaside) 831-796-2888 (Salinas) 831-678-5121 (Soledad) 831-386-6879 (King City) Merced County 1-888-381-5261
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No charge, but members must qualify. Services are billed under CPSP perinatal education, nutrition, psychosocial, and health education billing codes. No charge, but members must qualify. WIC requires physician visit/assessment for enrollment.
Alliance-Approved Lactation Consultant Providers (IBCLCs) The following providers are currently approved to provide lactation consultation for Alliance members when medically necessary. Other interested IBCLCs may contact the Senior Health Educator at (831) 430-5570 to apply. Dominican Hospital Outpatient Clinic Janet Hoover, LM, IBCLC 831-462-7862 Santa Cruz fax: 462-7720
Sonja Massey, RNC, IBCLC Baby Moon Pacific Grove
831-402-1666 fax: 657-9702
Watsonville Hospital Outpatient Clinic Kathryne Rockwood, RN, BSN, IBCLC Watsonville 831-768-6204 fax: 763-6438
Ruth Gingerich, PNP, IBCLC Children’s Health Services Carmel
831-624-9679 fax: 625-5521
Robin Didoszak, RNC, IBCLC Expressed Luv 831-869-9308 Marina fax: 582-9270
Monterey County Lactation Associates Charla Reehm, RN, BSN, IBCLC 831-384-2650 Marina fax: 384-8035
Natividad Medical Center Outpatient Clinic Carole Swain, RN, IBCLC 831-796-1652 Cheryl Hawkins, RN, IBCLC fax: 751-0607 Charla Reehm, RN, IBCLC Salinas
Emily Lindsey, BSPsy, IBCLC 209-383-1606 Before And After Baby fax: 722-8064 Merced
Please confirm that the patient is a current Alliance member prior to providing services by calling: Alliance Eligibility Clerks (831) 430-5502 M – F, 8:00 a.m. – 5:00 p.m.
Automated Eligibility Verification Line (831) 430-5501 24 hours
• Eligibility is established monthly, so please confirm eligibility at time of service. • Breastfeeding services and supplies may be billed under an eligible mom or eligible baby member. • Please note that professional services, rental, supplies and DME item cannot be billed to Medi-Cal for an amount greater than what is charged to the general public, per Title XXII. • If education is conducted as a home visit, bill only for education time. Travel time and expenses are not reimbursable. • For billing questions, please contact the Alliance Claims Department at (831) 430-5503 or your Provider Services Representative at (831) 430-5504.
Providers listed above may utilize the Alliance’s telephone interpreter service to communicate with Alliance members who have limited English proficiency. Please request an “Interpreter Services Quick Reference Guide” from your Provider Services Representative at (831) 430-5504 or download from the Alliance website at http://www.ccah-alliance.org/providerspdfs/InterpServQRGuide.pdf.
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