Reproductive Medicine

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Fertility Treatment and Insurance Benefits:

The topic of health insurance is a complicated one. But, health insurance coverage for infertility treatment is even more so, especially when there is no federal mandate for insurance carriers or employers to provide this type of health coverage in the U.S., and there are currently only fifteen (15) states that have enacted any such mandates. Unfortunately, Virginia is not one of these fifteen states, and although some health plans do provide coverage for basic fertility "testing", most do not provide coverage for fertility "treatment".

Although a few employers in Virginia have elected to provide fertility related coverage, they vary greatly from employer to employer, and from insurance company to insurance company, with even more variation based on the individual policy holder. All such plans typically require certain and specific medical criteria be met prior to initiating any type of testing or treatment. These companies usually require a prior authorization for services, without which, payment for claims will be denied and made the responsibility of the policy holder (you the patient).

Although a representative from our office contacts each patient's insurance company to inquire about their coverage and benefits, please understand that this does not constitute a guarantee of payment. Some insurance plan representatives may misquote benefits, and therefore, our office cannot accept responsibility for any inaccurate or incorrect information we may receive from your insurance carrier. Please remember, your insurance plan is a contract between you (the policy holder) and your insurance company.

As a result of these previously mentioned variations, requirements, and potential misinformation, it is very important for you, the policy holder and patient, to research your own insurance plan coverage. You should research this in terms of what services may, or may not, be covered for the evaluation and treatment of infertility. You can accomplish this either online or by calling the insurer or benefits representative. We recommend you do this prior to your first visit with our office.

Certainly, we understand that dealing with insurance companies can be intimidating at first glance, but to protect yourself from incurring fees that may not be covered by your insurance plan, you should obtain a written verification of your benefits, and you should provide our office with a copy of the information you receive.

Insurance companies have specific guidelines to help you determine the extent of your fertility benefits. They are obligated to provide you with this information. Typically, the information is delivered only in response to specific questions asked by the insured (you) and some important information may be omitted unintentionally.

To verify your insurance benefits, please refer to the customer service phone number printed on your insurance card. When verifying your benefits, you should:

1. Obtain the name of the customer service representative who provides the information.
2. Document the date and time of your phone call.
3. Request written confirmation of your specific benefits.

Review your benefits booklet, which should be available from your employer if you are part of a group plan. Make a copy of the section that pertains to infertility benefits. Please understand that if treatment is not covered by your insurance plan, our office does require payment at the time of service.

Fertility Questions to Ask Your Insurance Company:

If infertility is included in your policy coverage, you should ask the following questions:

1. Is my policy for diagnostic service only (i.e. for "testing to determine a/the cause of infertility"?)

2. Are the following Diagnostic Codes covered on my plan: 628.0 through 628.9?

3. Do I have coverage for the treatment of underlying conditions that may be the cause of my infertility?
  • A. A few examples: Endometriosis, Fibroids, Polycystic Ovarian Syndrome (PCOS), Pelvic Adhesions or Pelvic Adhesive Disease (PAD).

4. Would CPT codes 58322 & 58323, for an Intra-Uterine Insemination (IUI) be covered?

5. Would Advanced Reproductive Technology (ART) be covered – using the following CPT codes:

  • A. Fresh IVF: 58970 and 58974, for aspiration/retrieval and transfer,

  • B. 89250 through 89280 for the embryology lab services, and

  • C. Cryo/FET: embryology lab - 89352 thaw of cryopreserved embryos & 89255 for the transfer; and physician - 58974 for transfer of embryos

  • D. Specifically, would the following extra services (Micromanipulation Techniques) be covered?
    1. 1.AZH- Assisted Zona Hatching = CPT 89253
    2. 2. ICSI – Intra Cytoplasmic Sperm Injection = CPT's 89280 or 89281
    3. 3. Embryo Cryopreservation = CPT 89258

  • E. Are the above procedures covered with the diagnosis codes 628.0 through 628.9?

6. Is there a pre-existing clause on my policy in reference to infertility treatment or surgery procedures?

7. Do I have any fertility drug coverage?

  • A. If yes, where? (mail order or local pharmacy)
  • B. If yes, what drugs? (i.e. Bravelle, Follistim, Gonal F, Lupron, Menopur).

8. Do I need a referral and/or prior authorization for any office visits or procedures?

  • A. If yes, please obtain a referral before your visit with us. If you do not, your visit/services may not be covered

9. Do I have a yearly deductible that must be met?

  • A. If yes, how much is my deductible?
  • B. Have I met my deductible for this year?

10. What is my co-pay or co-insurance that will be due for my visits/services?

  • A. Co-pay: Flat fee/payment at each visit - such as $15, $25, $50, etc.
  • B. Co-insurance: A percentage of the charge or allowed amount - such as 10%, 20%, 50%.

The New Hope Center is an Infertility/Reproductive Endocrinology Specialist Office. As such, if you have a specialist co-pay/co-insurance, or if your deductible has not been met on your policy, you will need to be prepared to pay this amount for covered expenses.

Our goal at The New Hope Center is to assist you in overcoming your infertility issues, with the least amount of stress, and the least amount of cost to you as possible. However, we cannot code evaluation or treatment of infertility under non-fertility or alternate diagnostic codes, as that would be insurance fraud. Please, do not place our office staff or our physicians in the unfair position of having to decline a request for office to provide false information to your insurance company.

If you are being seen by our physicians for non-infertility medical issues or concerns, your diagnostic code will indicate this information. But, all fertility testing (such as HSG, CD #3 labs, Clomid Challenge Test, etc.) and treatment, both ART (such as IVF, Donor IVF, Frozen Transfer cycles, etc.) and non-ART (IUI's, Clomid or Ovulation Induction cycles, etc.), will be coded with the appropriate infertility diagnostic code.

If your insurance company does not provide fertility benefits, The New Hope Center does offer The C.A.R.E.S.© Program, which offers discount packages for both infertility testing and treatment services to help reduce the costs of your care. In addition, we offer a robust list of finance agencies and other lending options to assist patients with securing the finances needed for treatment.

Please refer to the Financial Assistance & Lending Options and the C.A.R.E.S.© Program sections on our website for more information.