Insurance Coverage
General Information
To Life! is an accredited facility through the Board of Certification/ Accreditation International (BOC).
As a provider of Durable Medical Equipment (DME), To Life! is a Medicare participating provider. We also have participating agreements with other insurance providers, such as:
Capital District Physicians Health Plan (CDPHP)
Highmark Blue Shield NENY
Anthem BCBS 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 you pay for wigs at the time of purchase and submit a claim to them for reimbursement. To Life! will provide the completed paperwork for you to submit.
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)
Please consult your insurance provider regarding coverage prior to your wig appointment. If you are expecting to utilize insurance coverage, you must bring a prescription from your medical provider to your 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:
- Do I need prior authorization?
- 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
Please consult your insurance provider regarding coverage prior to your fitting. If you are expecting to utilize insurance coverage, you must bring a prescription from your medical provider to your 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
Insurance providers have different policies regarding the number of mastectomy bras you can receive coverage for, and whether on a yearly or lifetime basis. Know your coverage so we can best serve you!
Questions to ask your 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?
- Am I allowed a swim prosthesis (L8020) as well as a regular prosthesis (L8030)?
Post-Surgical Camisoles
HCPCS Code: L8015
Please consult your insurance provider regarding coverage prior to your fitting. If you are expecting to utilize insurance coverage, you must bring a prescription from your medical provider to your appointment. You may also have your medical provider fax the prescription to our office.
Questions to ask your insurance company:
- Do I need prior authorization?
- Do I have a copay or other financial responsibility for this item?
- How many am I allowed in a year and lifetime?
Out of Network Coverage
If your insurance company is not one that To Life! participates with, you may inquire whether your insurer would provide “out of network” coverage. If the answer is yes, bring a letter or other directive that allows us to bill the insurer. When speaking with your insurance provider, be sure to collect the person’s name and any reference number from the conversation.
Questions to ask your insurance company:
- What are my out-of-network benefits?
- Will you reimburse To Life! directly or do I need to pay out-of-pocket and submit for reimbursement?
Insurance Myths and 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 or coinsurance associated with coverage. Depending on your coverage, your purchase from To Life! may be applied to your deductible. Review any relevant deductibles or coinsurance requirements with them prior to your appointment.