Apoyo para la Lactancia Materna y Beneficio de Extractor de Leche
The Alliance provides access to breastfeeding education, support and referrals for new mothers.
The Alliance covers up to two visits with a home health agency nurse and two hours with an International Board Certified Lactation Consultant (IBCLC) outside of the hospital stay (inpatient lactation education is included in the hospital per-diem). For a current list of approved providers, please refer to the International Board Certified Lactation Consultant and Breast Pump Provider Vendor List.
Members are eligible for a free breast pump if either:
- Mother or baby has medical issues that prevent nursing at the breast.
- Mother is returning to work or school and wants to continue breastfeeding.
The table below shares information on benefits, authorization and billing codes for Alliance member breastfeeding support. You can also view printable versions of the Breastfeeding Support and Breast Pump Benefit Description and the International Board Certified Lactation Consultants and Breast Pump Vendor List.
| Breastfeeding Support and Breast Pump Benefits Information | |||
| Benefit | Description | Authorization | Billing Codes |
| Lactation consultant visit |
|
No RAF or TAR required for 4 units per 12-month period for a total of two (2) hours.
Referred by doctor, mid-level professional, certified nurse midwife, Alliance staff or self-referral. |
CPT: Z5023* with a qualifying ICD-10 diagnoses code from categories O91, O92, P92, Z39 or Dx Code R63.3
Reimbursed at $45.74 per 30-minute unit. Limited to two (2) 30-minute units per visit. |
| Initial nurse home visit, postpartum |
|
A TAR is required, one (1) visit per day, except when services are in conjunction with the initial or six-month case evaluation. Includes supplies used as part of the treatment visit.
No limit on the number of daily visits. No TAR is required, one (1) service day limit. |
National HCPCS code G0300 must be billed with revenue code 0551, skilled nursing/visit. Standard reimbursement at $74.86.
National CPT-4 code 99501, home visit for postnatal assessment and follow-up care or 99502, home visit for newborn care and assessment must be billed with revenue code 0580. Standard reimbursement at $74.86. |
| Follow-up nurse home visit for identified breastfeeding problems |
|
No RAF or TAR required for one (1) visit per 12-month period. Home visit nurse will order at initial home visit, if needed. | CPT: Z5021* with a qualifying ICD-10.
Dx Code Z39.1. Reimbursed at $80. |
| Personal use of breast pump, purchase |
Nota:
|
No referral or authorization request required.*
Ordered by physician, mid-level professional, certified nurse midwife or IBCLC. Reimbursement to contracted pharmacies, contracted medical supply vendors or approved lactation consultants only. |
CPT: E0603 with a qualifying ICD-10 Dx code Z39.1.
Modifier: NU. Reimbursement at 80% of MSRP or up to $250, whichever is less. |
| Hospital grade electric breast pump, daily rental | Per Alliance Policy 405-2214 - Breastfeeding Support Benefits, Standards and Promotion Program, daily rental of a hospital grade breast pump will be covered when medically necessary. These conditions include, but are not limited to:
|
Authorization request required only if rental is to continue beyond 60 days.
Authorization request must include documentation of medical need, infant’s date of birth and requested duration of rental. Approved authorization requests will specify a time limit based on medical condition. Ordered by physician, mid-level professional, certified nurse midwife or IBCLC. |
CPT: E0604 with a qualifying ICD-10 Dx Code Z39.1.
Modifier: RR. 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)]. |
| Kit for hospital grade pump or manual breast pump, purchase |
|
No referral or authorization request required.
Ordered by physician, mid-level professional, midwife or IBCLC. |
CPT: E0602** with a qualifying ICD-10 Dx Code Z39.1.
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. |
| Miscellaneous medical supplies for lactation management and support, purchase | Includes nipple shields and creams.
Does not include furniture, pillows or bedding. |
Prescribed by doctor, mid-level professional or midwife. No referral or authorization request required for these supplies. | CPT: A9900 with a qualifying ICD-10 Dx code Z39.1.
Modifier: NU. Reimbursed at retail plus tax if pricing attached, or at estimated amount if no pricing sent. |
| Replacement breast pump supplies for lactation management and support, purchase | Includes:
|
A TAR must be submitted, justifying the need for any breast pump supply that needs to be replaced and may not be reimbursed when provided within the same month of service as breast pump codes E0602 and E0603. | CPT: A4281, A4282, A4283, A4284, A4285 and A4286 with a qualifying ICD-10 Dx code Z39.1.
Modifier: NU. Reimbursed at retail plus tax if pricing attached, or at estimated amount if no pricing sent. |
| *Alliance members are eligible for one personal use breast pump every three years. If there is a need for a second breast pump during the three-year period, an authorization request must be submitted with documentation stating the reason that the original pump cannot be used.
**Per Medi-Cal manual, E0602 may be used to bill either a manual breast pump or a breast pump kit. |
|||
Alliance-Approved Breast Pump Vendors
Any Durable Medical Equipment (DME) vendors with a Medi-Cal provider number may provide a breast pump to eligible Alliance members who are breastfeeding and meet medical necessity or who are returning to work or school. No prescription is required and only one breast pump will be dispensed every three years. Members must have a written note or letter from a physician, midlevel professional, certified nurse midwife or IBCLC. Written notes for breast pumps must include the following member information:
- Alliance ID number.
- Address.
- Número de teléfono.
- Delivery date.
Members may also call the Alliance Health Education Line at 800-700-3874, ext. 5580 for additional information on breastfeeding and how to access a breast pump. The following list of vendors routinely provides breast pumps for Alliance members.
| Alliance-Approved Breast Pump Vendor List | |||
| Condado de Santa Cruz | |||
| Horsnyder Pharmacy
1226 Soquel Ave., Santa Cruz, CA 95062 Phone: 831-458-1400 Fax: 831-458-1401 Electronic Fax: 831-534-7052
|
Watsonville Pharmacy
1433 Freedom Blvd., Watsonville, CA 95076 Phone: 831-728-1818 Fax: 831-728-8678 |
||
| Condado de Monterey | |||
| Robin Didoszak, IBCLC
Expressed Luv Phone: 831-869-9308 *Lactation/Pump Consultations |
|||
| Condado de Merced | |||
| Merced Medical Supply
1827 Canal St., Merced, CA 95340 Phone: 209-722-3832 Fax: 209-722-2779
|
Emily Bernard, BSPsy, IBCLC Before & After Baby
2239 Bailey Ave., Merced, CA 95341 Cell: 209-631-8511 Fax: 209-379-4218 *Lactation/Pump Consultations |
||
| DME Vendor List Serving all 3 Counties/Mail Order Only | |||
| Advance Home Medical*
Phone: 800-230-4761 Direct Line: 909-569-9013 Fax: 888-518-7568
*Upon request, may supply battery pack. |
Simply Mama*
Phone: 844-470-7867 Fax: 855-552-1461 *Upon request, may supply battery pack or car adapter. |
Shield Healthcare
Phone: 800-675-8842, select option 1. Santa Cruz County Fax: 925-256-1639 Monterey and Merced counties Fax: 559-449-4257 |
|
International Board Certified Lactation Consultants
IBCLCs provide comprehensive, clinical breastfeeding management and support when medically necessary. IBCLCs do not need a Medi-Cal provider number to bill for services. A provider referral is not necessary. Members may self-refer for lactation services.
The following providers are currently approved to provide lactation consultation for Alliance members when medically necessary.
If you are an IBCLC who is interested in providing services to Alliance members, please call the Alliance Health Education Line at 800-700-3874, ext. 5580 to apply.
| Alliance-Approved Lactation Consultant Providers | |||
| Condado de Santa Cruz | |||
| Willow Merchant, RN, IBCLC*
Phone: 650-862-9336 *Santa Cruz Mountains only - Boulder Creek, Ben Lomond, Felton and Bonny Doon (home visits). |
Sutter Maternity Surgery Center - Lactation Center*
2900 Chanticleer Ave., Santa Cruz, CA 95065 Teléfono: Fax: *Lactation consultations and drop-in breastfeeding support groups. |
Salud Para La Gente*
45 Neilson St., Teléfono: Fax: *Linked members only. |
Watsonville Hospital Outpatient Clinic*
75 Neilson St., Watsonville, CA 95076 Teléfono: Fax: *Linked members only. |
| Condado de Monterey | |||
| Natividad Medical Center Outpatient Clinic
1441 Constitution Blvd., Salinas, CA 93906 Phone: 831-796-1652 Fax: 831-751-0607 |
Robin Didoszak, IBCLC*
Expressed Luv Phone: 831-869-9308 *Lactation/pump consultations |
||
| Condado de Merced | |||
| Emily Bernard, BSPsy, IBCLC
Before & After Baby 2239 Bailey Ave., Merced, CA 95341 Cell: 209-631-8511 Fax: 209-379-4218 *Lactation/pump consultations |
|||
Billing
The services and equipment listed may be billed under either a mother or baby who is a current Alliance member. Billing limits apply to the mother/baby unit.
Please note that professional services, rental, supplies and durable medical equipment (DME) items 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.
Approved IBCLCs and DME vendors may bill for listed services and equipment under either mother or baby. Billing limits apply to the mother/baby unit.
| Additional Resources Available to Alliance Members (Bilingual English/Spanish) | |||
| Service | Description | How to Access | Fees |
| Breastfeeding Helpline (U.S. Department of Health and 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. | 800-994-9662 | Breastfeeding Helpline (U.S. Department of Health and Services) |
| Comprehensive Perinatal Services Program (CPSP) breastfeeding services |
|
County Perinatal Services Coordinators:
Condado de Santa Cruz Condado de Monterey 831-755-4640 Condado de Merced 209-381-1142 |
No charge, but members must qualify. Services are billed under CPSP perinatal education, nutrition, psychosocial and health education billing codes.
Medi-Cal members only. |
| Women, Infants and Children (WIC) program breastfeeding services |
|
Mothers should call WIC directly for enrollment:
Condado de Santa Cruz Santa Cruz Watsonville Condado de Monterey Seaside Salinas Soledad Condado de Merced 888-381-5261 |
No charge, but members must qualify. |
