PEIA PPB Plan Breastfeeding & Lactation Services
Pregnant and postpartum women have access to comprehensive lactation support and counseling from trained providers, as well as breastfeeding equipment. This policy provides guidelines for billing breast pumps and nursing related supplies and services for PEIA PPB Plan members. EFFECTIVE DATE: July 1, 2013 Updated: Effective July 1, 2015 COVERAGE: Who is covered – Any PPB plan participant who is covered for maternity services. Benefits – breastfeeding pumps, pump supplies, and counseling services are available to covered pregnant and postpartum participants. These benefits are covered up to 100% of the PEIA fee schedule with no deductibles, coinsurance or copayments. What is covered – breast pumps, pump supplies and counseling services are covered when billed as instructed below. PLAN GUIDELINES: 1. Breastfeeding pumps and pump supplies may be purchased through durable medical equipment (DME) company or at a retail store. a. Patient Reimbursement – In most cases, the patient will be required to pre-pay for the equipment and bill HealthSmart for reimbursement. Patients may submit a copy of the receipt to be reimbursed, the PEIA allowance, for these supplies. b. Provider Reimbursement – When the equipment is purchased through a “healthcare provider” the provider should bill HealthSmart directly and will be paid by HealthSmart. 2.
Lactation consultant services are also covered and must be provided by and billed by a qualified lactation specialist. This service may be offered through the OB/GYN office or the hospital providing delivery services.
BILLING FOR SERVICES: Providers must follow PEIA billing procedures and guidelines for PEIA PPB Plan members. Billing codes for Breastfeeding Pumps and Services
Fee Allowance (fees may change annually) E0602 NU Manual breast pump, new $ 27.52 E0603 NU Electric breast pump (AC or DC) $ 100.00* *Payment will not exceed the purchase price. Patient may choose to upgrade and pay the difference. Billing codes for Lactation Services CPT/HCPCS Code Code Description S9443 Lactation classes, non-physician provider, per session 98960 Education and training for patient self-management by a qualified non-physician healthcare professional using a standardized curriculum, face-to-face with patient; each 30 minutes; individual patient 98961 Education and training for patient self-management by a qualified non-physician healthcare professional using a standardized curriculum, face-to-face with patient; each 30 minutes; 2 – 4 patients 98962 Education and training for patient self-management by a qualified non-physician healthcare professional using a standardized curriculum, face-to-face with patient; each 30 minutes; 5 – 8 patients Additional Notes: •
Breast Pumps and pump supplies purchased outside WV, at a network provider, will be reimbursed at the network rate.
Breast Pump reimbursement is limited to once per pregnancy.
All in state providers providing lactation services are prohibited from billing the participant for amounts over the PEIA fee schedule.