Insurance Primer: Know Your Coverage
To Life! is an Accredited facility through the Board of Certification/Accreditation International (BOC). We have three locations in the Greater Capital Region that offer private in-person fittings for prostheses, bras, wigs and head coverings, in an environment that is private and comfortable. Our trained staff will assist you with the patience and care you deserve.
As a provider of Durable Medical Equipment (DME), To Life! is a Medicare participating provider. To Life! also has participating agreements with other insurance providers such as:
Capital District Physicians Health Plan (CDPHP)
Blue Shield of NENY
Empire Blue Cross/Blue Shield and its affiliates
*Medicare
Mohawk Valley Physicians (MVP)
**The Empire Plan
*Medicare does not provide insurance coverage for wig purchases.
**The Empire Plan requires that clients pay for wigs at the time of purchase and submit a claim to them for reimbursement.
To Life’s information:
Federal ID – 14-1808431
Reference Numbers:
Amsterdam NPI - 1366225690
Amsterdam PTAN - pending
Delmar NPI – 1750452322
Delmar PTAN – 1320150001
Saratoga NPI – 1992259188
Saratoga PTAN – 1320150002
Wigs:
HCPCS Code: A9282 - Cranial Prosthesis (Wig)
Clients are asked to call their insurance provider regarding coverage prior to their wig appointment. If the client is expecting to utilize insurance coverage, they must bring a prescription from their medical provider to their appointment. You may also have your medical provider fax the prescription to our office.
Amsterdam Fax #518-475-9141
Delmar Fax #518-475-9141
Saratoga Fax #518-587-3943
Questions to ask your insurance company:
What is my allowance for a Cranial Prosthesis (A9282)?
What is the “schedule of fees” for a A9282 (Wig)?
Do I have a copay or other financial responsibility for this item?
Prostheses and Bras:
HCPCS Codes: L8000, L8015, L8020, L8030, L8031, L8035
Clients are asked to call their insurance provider regarding coverage prior to their fitting. If the client is expecting to utilize insurance coverage, they must bring a prescription from their medical provider to their appointment. You may also have your medical provider fax the prescription to our office.
Amsterdam Fax #518-475-9141
Delmar Fax #518-475-9141
Saratoga Fax #518-587-3943
Questions to ask insurance company:
What is my allowance for mastectomy products?
What is the “schedule of fees” for products?
Do I have a copay or other financial responsibility for this item?
Prosthesis - How often are they replaced?
Bras – How many? How often?
Post-Surgical Camisoles:
HCPCS Code: L8015
These garments are available at To Life! and more than likely you have available coverage for one garment, however, there is usually an out-of-pocket expenditure from you.
Out of Network Coverage:
If your insurance company is not one that To Life! has a participating agreement with, the client may inquire as to whether the insurer would provide “out of network” coverage. If the answer is yes, then the client should bring a letter or some other directive that allows for us to bill the insurer for the product. When speaking with an insurance provider regarding coverage, be sure to collect name, and any reference number from the conversation.
Insurance providers have different policies regarding the number of mastectomy bras a client can receive coverage for whether on a yearly basis or for a lifetime. Know your coverage so we can best serve you!
Some Myths & Facts:
- Having a prescription from a doctor does not mean that the item you are purchasing is covered by insurance. It does mean that you should not be charged sales tax.
- There are very few insurance policies that pay 100% on every insured item.
- A provider does have the right to collect a copay & a price difference beforehand at the time of purchase.
- When you switch from one insurance company to another you are not entitled to “start all over”. Your purchase history goes to your new company along with your health maintenance information.
- More than likely if your primary insurance does not participate in the purchase of an item, it is extremely rare that your secondary insurer will pay any part of that item.
- Many insurance plans have a deductible associated with coverage. Depending on your coverage, your purchase from To Life! may be applied to your deductible. Review any relevant deductible with them prior to your appointment.