CurrentAnthemPolicy N/A

Electric non-hospital grade breast pump request form (Anthem HealthKeepers Plus)

Form and instructions for requesting an electric, non-hospital grade breast pump (suggested Ameda Finesse) for Anthem HealthKeepers Plus Medicaid members; describes required member/provider information, eligibility (member must be Anthem HealthKeepers Plus), delivery timing, and submission contact details.

Policy Summary

PayerAnthem HealthKeepers Plus (HealthKeepers, Inc.)

PolicyElectric non-hospital grade breast pump request form (Anthem HealthKeepers Plus)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete the Electric, Nonhospital Grade Breast Pump Request Form (or attach a face sheet with required demographics), sign to certify medical necessity, and submit via pumpprescriptions@edgepark.com or fax to 330-963-6172.

POLICY UPDATE CHANGES

No material clinical/coverage changes

AmedaSuggested pump model

HealthKeepers PlusApplicable payer product

30Max pre-delivery fulfillment window (days)

Policy summary and at-a-glance

This communication serves as a replacement for a prescription for Anthem HealthKeepers Plus members requesting an electric, non-hospital grade breast pump. It explains required member/provider information, eligibility, delivery timing, and submission instructions.

Eligibility and fulfillment conditions

Eligibility and Fulfillment Conditions

Pump will be provided when ALL of the following are met:

ALL of the following

Mom and baby must be Anthem HealthKeepers Plus members
Completed request form submitted (or face sheet with demographics attached) with required fields
Request is for an electric breast pump (nonhospital grade), ICD-10: Z39.1
Delivery timing
- Pump may be delivered up to 30 days before delivery (use estimated due date)
- Pump may be delivered upon notice that baby has been born; if baby already born, pump fulfilled once form received and information validated

ref():": "b1_0"

title": "Eligibility and Fulfillment Conditions"

Coverage stance: Mixed — the Ameda Finesse is recommended but not required; members may choose an alternate pump model.

Operational note: Additional no-cost member benefits (online resources, lactation support professionals, dedicated call center, and communications) apply only to members receiving Ameda brand breast pumps.

What providers must do

Documentation Required

Complete request form

Providers must complete the specified Electric, Nonhospital Grade Breast Pump Request Form (or attach a face sheet with required demographic information) and certify medical necessity with signature and date.

Provider signature required
Today's date required

Documentation Required

Required patient fields

Form must include required member fields denoted by '*' or attach a face sheet containing the demographic information.

Member's name (mother)
Member's Anthem HealthKeepers Plus ID (mother)
Member's DOB (mother)
Estimated due date OR Infant's birthdate
Member's shipping address
Member's phone number

Billing Rule

Submission channels

Submit the completed form via email to pumpprescriptions@edgepark.com or fax to 330-963-6172.

Policy Summary

PayerAnthem HealthKeepers Plus (HealthKeepers, Inc.)

PolicyElectric non-hospital grade breast pump request form (Anthem HealthKeepers Plus)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

On This Page

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Electric non-hospital grade breast pump request form (Anthem HealthKeepers Plus)

Policy summary and at-a-glance

Eligibility and fulfillment conditions

Coding guidance

What providers must do

Definitions

Document history