How to Get Consults Covered through Aetna

*subject to change

Please note, Lake Norman Breastfeeding Solutions is out of network with Aetna. These steps to get consults covered with an in-network exception were created solely by LKNBS, to help clients who have Aetna insurance.

Step 1 - Check for In-Network Consultants

Use your Aetna app or the Aetna website to search for participating/in-network lactation consultants in your area. If none are within a reasonable distance, you should be able to require Aetna to pay for your lactation consults with the provider of your choosing.

Step 2 - Call Aetna

Call Aetna using the phone number on your insurance card and let them know there are no participating lactation consultants in your area so would like them to grant “network gap approval” for Lake Norman Breastfeeding Solutions to be covered at an in-network benefit level. (This means you will not have to pay for consults.) They may ask for the following information on how we bill for consults:

Tax ID/EIN: 81-4920991

NPI (National Provider Identifier) - Group NPI: 1770029001

Procedure Codes: 99404, S9443

Diagnosis Code: Z39.1

*The procedure codes and diagnosis code are crucial in ensuring correct billing after your consultation

Once you speak with Aetna, it may take 7-10 business days (or more) for a decision to be made. If your request is approved, a preauthorization letter will be mailed to us directly and we will notify you upon arrival. It is preferred that the preauthorization is received prior to your consult; however, see note at bottom of the page.

Step 3 - Billing After Consult

If Aetna provides written preauthorization, we will submit the claims for you and bill Aetna for up to 6 lactation consults (note: Aetna typically includes the number of visits authorized in the preauthorization letter). According to the Affordable Care Act, lactation consults fall within the preventative care umbrella which means they should be covered 100% by insurance and not applied to your deductible. However, we require your credit, debit card or HSA card number to be kept on file in the event that Aetna does not cover the consults as agreed. If they deny the claim we will appeal once, if claim is denied again we will bill the credit card on file for discounted rate of $175.00 per consult. Sometimes billing can take 30+ days, but we will keep you updated as we have information.

If you are unable to gain preauthorization, you can pay out of pocket for the consult and then later submit the claims to Aetna. We recommend still calling Aetna to obtain a network gap exception (step 2) if possible.