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Insurance Primer: Know Your Coverage!

To Life! is an accredited facility through the American Board for Certification in Orthotics, Prosthetics and Pedorthics. We provide boutique services throughout the Greater Capital Region and surrounding 10 counties where women being treated for breast cancer can shop in a private and comfortable setting and be fitted for prosthesis, bras, wigs and hats. Our certified and 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 the following insurance providers:

CDPHP

Blue Cross Blue Shield of NENY

Empire Blue Cross

Medicare

MVP

Important Numbers:

To Life! Federal ID Number: 14-1808431

Reference Numbers:

            Delmar NPI – 1750452322

            Delmar PTAN – 132015000

            Saratoga NPI – 1992259188

            Saratoga PTAN – 132015000

Please know that To Life! will make every effort to help you leverage your insurance coverage. In recent years, we have seen many changes to policies and procedures for claims. It can be a very complcated business. Please know that we are committed to help you with the financial aspect of your purchase.  

WIGS:

HCPCS Code

A9282 - Cranial Prosthesis (Wig)

Clients are asked to call their insurance provider prior to their wig fitting. If a client is expecting to utilize insurance coverage, they must bring a script from a doctor at time of purchase. Any physician is fine, including surgeon, oncologist, primary care, or gynecologist.

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)?

What is my co-pay for this item?

If the insurance company is not one that To Life! has a participating agreement with, the client will be expected to pay for selected items at time of purchase. You may inquire as to whether the insurer would provide coverage “out of network”. If the answer is yes, then the client should bring a letter or some other directive. We can assist with paperwork needed for you to file a claim.

Prosthesis and Bras:

HCPCS Codes

L8000 – Breast Prosthesis, Mastectomy Bra

L8030 – Breast Prosthesis, Silicone or Equal

L8015 - Post Surgical Camisoles - These garments are available at To Life! and more than likely you have available coverage for one garment, however, there is always a co-pay and an out of pocket expenditure from you.  Some policies include the same amount of coverage for a second garment.

Clients are asked to call their insurance provider prior to their mastectomy fitting. If client is expecting to utilize insurance coverage, they must bring a script from their doctor at time of purchase.

Questions to ask your insurance company:

What is my allowance for mastectomy products L8000 and L8030?

What is the “schedule of fees” for products?

What is my co-pay for this item?

Prosthesis - How often are they replaced?

Bras – How many? How often?

If the insurance company is not one that To Life! has a participating agreement with, the client may inquire as to whether the insurer would provide coverage “out of network”. If the answer is yes, then the client should bring a letter or some other directive. Even when speaking with an insurer that has a participating agreement with To Life!, be sure to collect name, and any reference number from the conversation. Even with a directive, To Life! reserves the right to ask for payment at time of service for "out of network" cases.

All insurances have different policies regarding the number of mastectomy bras available to the insured – on a yearly basis or for a lifetime.  Know your coverage so we can best serve you!

Some Insurance Myths & Facts:

  • Because you have a prescription from a doctor does not mean that the item is therefore 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.
  • 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 will pay any part of that item.
  • Many plans have a deductible amount associated with coverage. When collecting information from your insurance, review any relevant deductible with them prior to your boutique visit.