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Assisted reproductive technology (ART) offer safe and effective therapies for couples who are struggling to get pregnant. ART includes In Vitro Fertilization (IVF) or the use of an egg donor, sperm donor or adopted embryo. Up to I million babies were born in the United States between 1987 and 2015 through the use of IVF or other ART, according to a report released in 2017 by the by the U.S. Society of Assisted Reproductive Technology (SART). Coverage for infertility treatment varies widely among insurance plans and among states. Reproductive medicine verifications and authorizations are an essential part of providing treatment for insured seeking fertility treatment.

Fertility Treatment and Insurance Coverage

Infertility is caused by both female and male factors. Common reasons for infertility include ovulation problems, structural problems with the uterus or fallopian tubes, hormonal factors and problems with sperm quality or motility. About 25% of the time, there is more than one reason for infertility and about 15 percent of infertile couples have a diagnosis of unexplained infertility (idiopathic infertility).

Infertility is treated using a series of complex procedures that includes hormone treatments, fertility drugs, lab work, anesthesia, surgery, intrauterine insemination, or ART. Fertility treatment is expensive and not covered by all insurers. Many insurers offer fertility insurance under health care plans and not as a separate health insurance policy. Coverage is provided for the diagnostics and treatments needed to help parents struggling to conceive or carry a pregnancy to term.

Some plans cover IVF as well as the accompanying injections that women may also require. Other plans cover only IVF while other plans do not cover IVF at all. Some plans cover only a certain number of attempts at certain treatments. No Medicaid program covers artificial insemination or in-vitro fertilization and New York is the only state where the Medicaid program covers any fertility treatment. As of June 2022, 20 states have passed fertility insurance coverage laws, 14 of those laws include IVF coverage, and 12 states have fertility preservation laws for iatrogenic (medically-induced) infertility. (https://resolve.org/).

In-Vitro Fertilization Verifications and Authorizations

Gynecologists and infertility specialists providing in-vitro fertilization treatment need to verify patient coverage before services are provided. As indicated above, coverage for infertility diagnosis and treatment varies among insurers and among states. For example, though insurance plans in New York are required to provide coverage for infertility treatment and diagnosis, IVF and egg freezing are excluded from the mandate.

Insurance companies use very specific guidelines to determine the extent of each member’s infertility benefits and how their claims will be processed. For example, Cigna’s policy for infertility injectables states: “When coverage is available and medically necessary, the dosage, frequency, duration of therapy, and site of care should be reasonable, clinically appropriate, and supported by evidence-based literature and adjusted based upon severity, alternative available treatments, and previous response to therapy”.

Insurance verification, a key step in medical billing, involves verifying a patient’s eligibility for services. Eligibility issues are the one of the most common reasons for claim denials. IVF verifications are critical before starting the treatment cycle to enable the patient understand what the insurance plan will cover and for the provider to submit accurate claims. Partnering with an insurance verification expert is the best option for infertility specialists to carry through this important but tedious task.

In-vitro verifications will cover verifying the following:

  • Patient demographic information
  • Type of plan
  • Claims mailing address
  • Whether the provider is in the insurance plan’s network
  • Patient’s financial responsibility: copays, deductibles and out-of-pocket limits
  • Patient policy status
  • Effective date
  • Payable benefits
  • Plan exclusions
  • Insurance caps
  • Primary and secondary insurers
  • Out of network benefits
  • Referrals and pre-authorizations

In addition to this basic information, specific in-vitro verification is done for:

  • Infertility benefits as well as any benefit exclusions
  • Whether specific medical criteria should be met to be eligible for infertility benefits:
  • Whether the plan requires a documented diagnosis
  • Whether the patient should undergo lesser treatments (IUI) before proceeding to advanced treatments (IVF/ICSI)
  • Whether IVF/ICSI only be paid for certain diagnoses
  • If there any limit, dollar or number, on treatment cycles
  • If there any factors that would cause denial of benefits, for e.g., prior failed treatment, prior sterilization
  • Coverage for male infertility diagnosis and infertility care
  • Lifetime maximums for infertility treatment

Prior Authorization for Infertility Treatment

Most health insurance companies require providers to obtain approval from the patient’s plan before they will cover the costs of a specific medicine, medical device or procedure. Completing prior authorization or pre-authorization requirements is a key process to avoid claim denials.

Many insurance plans require prior authorization, precertification, or registration with infertility case management when it is determined that infertility treatment is appropriate. After the provider and patient agree on a treatment plan, performing treatment authorizations will help in-network infertility specialists determine what infertility treatments, medications, and procedures will covered under the patient’s health plan.

Steps to obtain preauthorization for IVF treatment:

  • Once there is a plan for infertility treatment using ovulation induction with injectable fertility medications, artificial insemination, or assisted reproductive technology (ART), the provider has to submit a precertification using the insurer’s designated request forms.
  • The pre-authorization request should be submitted before the treatment is started.
  • The treatment plan should be submitted to the insurer along with any pertinent clinical information.
  • The health insurer will use the information submitted by the provider to determine if the patient is eligible to access the applicable infertility benefit.
  • The requested services or procedures should be submitted with the appropriate CPT, CDT or HCPCS Code and supporting diagnoses with ICD-10 Code).

Estimates for patient responsibility such as deductibles and co-insurance are not typically included in the cost calculation. For example, UnitedHealthcare usually pays around 80% in cost-sharing plans and the patient may have to pay for 20% of covered fertility services. Preauthorization for IVF procedures generally takes about 1-2 weeks. Medication preauthorization may be obtained faster.

Prior authorization is not a guarantee that a health plan will cover the cost but not obtaining a pre-approval can cause non-payment or denial of the claim.

Outsource In-Vitro Fertilization Verifications and Authorizations

Being diagnosed with infertility and obtaining fertility treatment can cause anxiety and stress. Allowing an expert to handle reproductive medicine verifications and authorizations can help fertility specialists focus on their patients.

Leading medical billing companies in the U.S. have a team of insurance verification specialists who are knowledgeable about insurer rules and requirements for fertility treatments, including state laws. They can handle the preauthorization process quickly and smoothly, minimizing patient concerns about unforeseen costs and helping providers reduce administrative hassles and get paid for covered services.