Self-pay reimbursement

To get reimbursed by your health insurance company for covered services you've already paid for, follow these steps:

1. Check Your Policy

• Review your health insurance policy to confirm:

• The service is covered.

• You're eligible for reimbursement.

• The provider didn’t bill the insurance directly.

2. Collect Required Documents

You’ll typically need:

• Itemized receipt or bill: Must show provider details, service dates, descriptions, and costs.

• Proof of payment: A receipt, credit card statement, or bank record showing you paid.

• Insurance claim form: Download this from your insurer’s website or call customer service.

3. Fill Out the Claim Form

Include:

• Your member ID

• Provider info (name, address, NPI)

• Date and type of service

• Diagnosis and procedure codes (ICD-10, CPT) — Service details will be on your superbill

4. Submit the Claim

• Send it to the insurer’s claims address, usually found on your insurance card or their website.

• Submission methods: Mail, fax, or online portal, depending on your insurer.

5. Track Your Claim

• Log in to your insurance account or call to check claim status.

• Keep copies of everything submitted.

6. Receive Reimbursement

• If approved, you’ll receive a check or direct deposit.

• You’ll also get an Explanation of Benefits (EOB) showing what was paid and why.

Optional:

By receiving an order from your physician, checking the codes, and granting a “gap exception” to your provider, you can greatly increase the chances of reimbursement. A Gap exception gets your IBCLC in-network temporarily. Companies make it very difficult for a Lactation Consultant to be in network. However, you can many times request a “gap exception” to grant your consultant temporary in-network status. Explain that you want your provider to be in-network because:

1. No other in-network provider is in the area

2. The provider is the only one who offers the services and specialty that you seek

Tips:

• Submit claims within the time limit (usually 90 days to 1 year from service date).

• If denied, you have the right to appeal—follow the insurer’s appeal process.