How insurance works
The mechanics of insurance billing here
We are in-network with nine major carriers, and many other plans bill through Aetna or UnitedHealthcare.
Wondering if you’re covered? Preview my coverage →
Verification opens our secure intake form. Most weekday submissions reviewed in 1–2 business days.
Houston: (281) 305-0411 San Antonio & Boerne: (210) 319-4988
How a claim flows
Three ways billing plays out
What happens after your visit depends on whether your plan is in-network with us, out-of-network with out-of-network (OON) benefits, or out-of-network without them. Pick your situation to see who pays whom.
Your plan is in-network with us (nine major carriers, plus the third-party administrators that route through them). We bill insurance directly; you pay only your share, typically a copay, coinsurance, or any unmet deductible.
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You
BCB1
Schedule and share insurance
You book online and complete insurance info in the patient portal. Billing verifies benefits and emails a written estimate before the visit.
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BCB
Insurance2
File the claim
After your visit, we submit the claim with the procedure and medical codes for what was done.
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Insurance
BCB3
Pay the negotiated rate
Insurance pays us the contracted in-network rate for the codes filed. This is the heavy lifting on the financial side.
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BCB
You4
Bill any patient responsibility
If your plan has a copay, coinsurance, or unmet deductible for the visit, we charge the card on file. Most patients owe little to nothing.
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Insurance
You5
Send the EOB
A few weeks later, the Explanation of Benefits arrives. It’s not a bill. It confirms what insurance paid and what you owed.
Your plan is not in-network with us, but it includes out-of-network benefits (most PPOs do). You pay us at the visit and then submit a superbill to your insurance for reimbursement.
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You
BCB1
Pay self-pay rate at the visit
Card on file or upfront payment at our posted self-pay rates. Insurance is not billed directly.
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BCB
You2
Itemized superbill
We send an itemized receipt with the procedure and medical codes, our NPI, and tax ID, everything your carrier needs to process an out-of-network claim.
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You
Insurance3
Submit the OON claim
Upload the superbill via your carrier’s member portal or app. Most carriers have an online OON-claim form; some still require mail.
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Insurance
You4
Reimburse you directly
Within two to six weeks, you receive an EOB plus a check or direct deposit for whatever your OON benefit covers, often a percentage after your OON deductible.
Step-by-step instructions for submitting the superbill (and what to do if your claim is denied) on Using Your Superbill.
Your plan does not include out-of-network benefits.
HMOs, EPOs, Medicaid, and most Marketplace plans fall into this category.
Insurance doesn’t enter the picture. Care is self-pay.
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You
BCB1
Pay self-pay rate at the visit
Posted self-pay rates apply. Card on file or upfront payment. HSA and FSA funds are eligible.
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BCB
You2
Itemized receipt for HSA / FSA
We send a clean receipt suitable for HSA/FSA reimbursement and for your own records. No claim is filed with insurance.
Self-pay rates, payment plans, and health-share options on Self-Pay and Health-Share.
In-network carriers
Nine Major Carriers
Direct in-network for these nine. Tap any card for plan-specific rules, carve-outs, and FAQs.
Aetna
Plus a long list of third-party administrators that route through Aetna’s network.
Aetna details
Blue Cross Blue Shield
Texas, Federal, UT Health Select, Anthem PPO, out-of-state plans.
BCBS details
Cigna
Routed through Wildflower. PPO only; HMO is self-pay.
Cigna details
Curative
Texas-only, employer-sponsored plans with $0 cost sharing on most benefits.
Curative details
Humana
Direct in-network. Medicaid and Medicare Advantage products excluded.
Humana details
MultiPlan
In-network through the MultiPlan / Imagine 360 partnership. PHCS also routes here.
MultiPlan details
Sana Benefits
Direct contract for Sana members. ACA preventive applies.
Sana details
TRICARE
In-network for TRICARE West. Lactation covered for mom only.
TRICARE details
United Healthcare
Plus UMR, Surest, Bind, Oxford, AllSavers, and other UHC-family administrators.
UHC detailsHow it works
How we work with your insurance
Four steps from scheduling to claim, with a written estimate before your visit.
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1
Schedule
Book your appointment, then complete your final insurance information in our Jane patient portal. We need this before your visit to verify benefits and send your written estimate.
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2
Verify
Billing contacts your carrier to confirm in-network status, copay or coinsurance, deductible, visit limits, and referral requirements.
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3
Estimate
Most patients have little to no out-of-pocket cost. We’ll email you any expected costs in writing before your visit, so there are no surprises.
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4
Claim
After your visit we file the claim. Any patient responsibility (copay, coinsurance, deductible) bills to the card on file.
One honest note about verification. We confirm we are in-network with your plan and check for preventive lactation coverage where the carrier shows it. Some plans don’t display lactation-specific benefits in their online portals; we call when applicable, and even then, what a representative tells us isn’t always accurate. We share what we can confirm in writing, but knowing your specific plan benefits is ultimately your responsibility.
What is included
Typically covered vs. patient-billed
General patterns across the carriers we work with. Your written estimate confirms specifics for your plan.
Typically covered
- Initial postpartum lactation consultation (in-office)
- Follow-up lactation visits within plan limits
- Prenatal lactation consultation
- Tongue-tie and oral function assessment
- Pumping and flange-fit consultation
- Return-to-work consultation
- Telehealth lactation visits (most plans; some carriers exclude)
- Home visits, when offered (most plans; some carriers exclude; travel fee patient-billed)
Patient-billed regardless of plan
- Home visit travel fee ($70)
- Late-cancellation fees
- No-show fees
- Holiday-rate fees
- Visits beyond plan-allowed limits
- Visits where a required referral was not obtained
- Chiropractic care and PBM (laser therapy) are cash-pay services, not billed under your medical plan
The two lists above describe general patterns, not guarantees for any specific plan. Your verification email confirms exactly what applies.
Billing partners
Why some plans route through Wildflower or TLN
A handful of plans don’t pay IBCLCs directly; they route claims through a billing partner. Nothing changes on your end, we handle the routing.
Billing partner
The Lactation Network (TLN)
Used for certain BCBS PPO plans, UHC Oxford plans, and some Aetna plans. TLN credentials our IBCLCs, processes the claim, and pays us; you’ll receive an EOB from your carrier as usual.
Billing partner
Wildflower Health
Used for Cigna PPO plans. Same idea as TLN: claim routes through Wildflower, billed under your Cigna preventive benefit when applicable.
Card on file & savings
Card on File and HSA / FSA
What we keep on file at booking, and how to use HSA or FSA dollars for your visits.
Card on file
Why we keep a card on file
A card on file is required to schedule your initial visit. We do not run unauthorized charges; the card secures the appointment and covers patient-billed amounts only.
Authorized uses:
- Late-cancellation and no-show fees
- Home-visit travel fee
- Copay, coinsurance, or deductible after the claim is adjudicated
- Non-covered services (visits beyond plan limits, chiropractic care, photobiomodulation therapy)
- Product purchases (nipple shields, supplements, supplies)
- Self-pay charges for patients not covered by an in-network plan
HSA / FSA
HSA and FSA usage
Lactation consultations and related fees are HSA- and FSA-eligible. If you’re on a high-deductible plan, you can use your HSA or FSA card to pay copays, coinsurance, deductibles, home-visit travel fees, and self-pay portions of your visit.
We provide an itemized receipt suitable for HSA/FSA documentation after each visit.
Cash-pay services
Chiropractic and PBM are cash-pay
Chiropractic care and photobiomodulation (PBM) therapy are cash-pay services and are not billed under your medical insurance, regardless of carrier. Rates are confirmed in writing during scheduling, before your first appointment.
This is the most common point of patient confusion when a family books across services. A lactation visit may be covered at $0 under ACA preventive while a chiropractic adjustment for the same baby is a separate cash-pay charge. We separate the two clearly so you know what to expect.
Common questions
Frequently asked questions
Tap any question to expand. For carrier-specific questions, see the carrier page above.
Coverage basics
What is the difference between in-network and out-of-network?
An in-network provider has a contracted rate with your carrier. Claims process under your in-network benefit (often $0 cost share for ACA preventive lactation visits). Out-of-network providers are not contracted; the carrier may apply higher cost sharing or deny the claim entirely. Some plans offer no out-of-network benefit at all, in which case the visit becomes self-pay with a superbill for you to submit on your own.
What if my carrier is not on your list?
Submit verification anyway. Some carriers are still billable out-of-network or through one of our billing partners. If neither applies, we’ll quote you the self-pay rate in writing and provide a superbill so you can attempt patient-side reimbursement.
What about my baby, is the baby billed too?
We bill on baby whenever we can. If mom and baby are on different plans, we always submit a claim on each. If they share the same plan and that plan allows two claims (most do), we bill both. A few systems, most BCBS, Cigna, and TRICARE, only allow a single claim per visit when mom and baby share a plan, so on those we bill the lactating parent only. Some Aetna-network third-party administrators pay one side per visit and apply a non-covered infant fee instead.
Fees and billing
Why do I need to provide a credit card before my first appointment?
The card on file is required to schedule. Authorized uses are listed in the Why we keep a card on file section: late-cancellation, no-show, home-visit travel fee, post-claim patient responsibility, non-covered services, and self-pay charges. We don’t run unauthorized charges.
Are home visits covered? Is there a home-visit fee?
Yes. Home visits are billable to most plans we work with under home-visit codes. The visit itself bills to your insurance the same way an office visit does. A separate $70 travel fee is billed to your card on file regardless of plan; this fee covers the IBCLC’s travel time.
Are there cancellation, no-show, or holiday fees?
Yes. Late cancellations (under 48 hours’ notice), no-shows, and holiday visits incur fees. Because we do not double-book, a late cancellation often means we cannot fill that spot, and it may mean another family did not get seen, which is why a cancellation fee applies. Specific amounts are in our payment consent form and will be confirmed when you schedule.
How do I submit a superbill for reimbursement?
A superbill is an itemized receipt with the diagnosis and procedure codes your carrier needs to process an out-of-network claim. After your visit, request one and submit it to your carrier with their out-of-network claim form, usually through their member portal or by mail. They’ll process it under your out-of-network benefit and send reimbursement directly to you.
What if my visit is denied by insurance?
If a claim is denied (most often because a required referral wasn’t obtained, or because plan limits were reached), the visit is billed as self-pay to your card on file. Verification flags referral and limit risks before you visit so this almost never happens unexpectedly.
Verification & scheduling
Do I need to wait for my insurance to be verified before booking my appointment?
No. You can book your appointment before your insurance is verified. As long as you submit your insurance information at least 1–2 business days (Monday through Friday) before your appointment, our team will have enough time to verify your coverage prior to your visit. If you are submitting the day before your scheduled visit, please submit by 3 PM so we have time to verify.
If we discover that your plan is not covered or has unusual restrictions, we will notify you by email and text message. If you decide to cancel your appointment due to lack of coverage, we will waive the cancellation fee as long as you request cancellation on the same day we notify you.
How long does verification take?
Most weekday submissions before 3 PM are reviewed the same day. Worst case is one to two business days. After you book, you’ll receive an email with your verified benefits before your visit.
What does the written estimate include?
Carrier name, plan name, in-network status, applicable copay or coinsurance, deductible status, visit limits, any required referral, and your expected out-of-pocket cost for the first visit. If you have follow-ups planned, we estimate those too.
Visit limits
What happens after my plan’s visit limit?
Visits beyond plan limits are billed at our self-pay rate to your card on file. Many plans cap lactation visits at three to six per pregnancy or per year; some cover unlimited visits. Verification gives you the count.
What counts toward my plan’s visit limit?
Any lactation visit billed to your plan counts, including visits provided by other lactation programs, breast-pump-company prenatal classes that bill as lactation visits, and visits at hospital lactation clinics. Our own prenatal breast pump class is parent education, not a billed lactation visit, so it does not count toward your limit. If you’ve used lactation visits elsewhere this year, tell us during verification so we can build that into the estimate.
Get your benefits verified, in writing
Submit the secure form to schedule your visit. Our billing team will confirm your coverage and email a written estimate before your appointment, usually within one to two business days.
Start your intakeOpens our intake form in a separate, HIPAA-secure system (new tab).
Wondering if you’re covered? Preview my coverage →
Opens our secure intake form.Houston: (281) 305-0411 · San Antonio & Boerne: (210) 319-4988