Insurance companies are really good at tightening their purse strings. They can very easily find a way with mumbo-jumbo language to make you feel like what you're asking for is too much cough cough FREE and ACCESSIBLE lactation and postpartum care.

As a provider in-network as well as a provider who has tried to infiltrate the brick walls of some insurance companies to become in network, I see behind the scenes and there's very shall I say... interesting things that they do to avoid paying for this care. For example, they insist that the provider must be an IBCLC + another healthcare license, they insist the provider must be an MD, DO, NP, or they have 1 pediatrician practice in an inconvenient location that has lactation care in their network but that practice isn't even your pediatrician.

New Jersey, heck yea, to the amazing LCs who fought and fought and got laws passed to further cover their residents. This makes it A LOT easier to get your $ back.

The last, and I mean very last thing you should be doing as a postpartum mother is calling insurance and waiting on hold to argue with someone for reimbursement.

So, please send this blog post to your partner, mom, friend, neighbor. Anyone else but you. Because you should be chest to chest with your new baby and relaxing.

Here's a script with some talking points for when NOT YOU (remember, you're resting!!!) calls:

pro tip: stay nearby in case insurance needs your verbal authorization to proceed with your designated insurance warrior

“Hi, my name is ___. I’m a New Jersey resident calling about reimbursement for lactation support services I received and submitted via a superbill. I want to confirm how my plan complies with both the Affordable Care Act and New Jersey state law regarding breastfeeding support.”

“New Jersey law requires health insurance plans to cover breastfeeding support and counseling as preventive care. This includes lactation counseling and services, and the coverage cannot be limited in a way that makes access unreasonable.”

let them answer.

“I want to be clear that the requirement is coverage of breastfeeding support and counseling services, not coverage based on a single certification title. The services must be covered when provided by a qualified, licensed healthcare provider acting within their scope of practice.”

“In my case, the lactation services were medically necessary postpartum care. They addressed feeding-related concerns that required timely intervention to prevent clinical complications such as ineffective feeding, poor infant weight gain, maternal breast complications, or premature cessation of breastfeeding.”

“This was not elective care. Postpartum lactation issues are time-sensitive, and delays can directly worsen outcomes for both the infant and the parent.”

Superbill

“I have a detailed superbill documenting:

• Dates and duration of care

• The nature of the breastfeeding support and counseling provided

• Diagnosis information supporting medical necessity

• Provider licensing and credentials

I’m requesting reimbursement based on this superbill under preventive services coverage.”

Reasonable distance: defined clinically, not subjectively

“I was told there may be in-network lactation providers available. I need to clarify what the plan considers ‘reasonable access’ under New Jersey law.”

“For postpartum lactation care, reasonable access must account for:

• The time-sensitive nature of feeding issues

• Postpartum physical recovery

• Infant feeding frequency and safety

• The risk of clinical deterioration if care is delayed”

“A provider who is far away, has long wait times, or cannot see postpartum patients promptly does not meet reasonable access standards for medically necessary lactation care.”

Force specificity

“Can you tell me:

• The closest in-network provider who offers breastfeeding support

• Their distance from my home

• Their typical wait time for a new postpartum patient

• Whether timely care was realistically available at the time I needed services”

let them answer.

If access was inadequate

“Based on that information, timely and reasonable access was not available. Under New Jersey law, when a plan cannot provide accessible in-network breastfeeding support, the plan must cover the service without imposing barriers or denying reimbursement solely due to network limitations.”

Direct reimbursement request

“I’m requesting reimbursement for the lactation services I received, submitted via superbill, processed as medically necessary preventive care under New Jersey law and the ACA.”

If they push back on credentialing

“I’m not requesting coverage based on a specific certification. I’m requesting coverage for breastfeeding support and counseling services required by New Jersey law and provided within a licensed healthcare provider’s scope of practice.”

Escalation language

“If reimbursement is being denied, I’m requesting:

• Written confirmation that no timely and accessible in-network breastfeeding support provider was available, or

• Authorization of out-of-network reimbursement based on medical necessity and access limitations, or

• Escalation to a supervisor or medical management department familiar with New Jersey preventive services requirements.”

• 
  

Appeal setup

“Please document this call as a request under New Jersey’s breastfeeding support coverage law and the ACA. If needed, I will request a formal coverage determination and submit a written appeal.”

IMPORTANT!!!

“Can you provide a reference number for this call and confirm the next steps and timeline for reimbursement?”

good luck girlfriend, fingers crossed.

xo,

Jenna