CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Lactation Consultations

Governs coverage and billing requirements for lactation consultation services for BCBSRI members, including provider qualifications and applicable codes; applies to Medicare Advantage and Commercial products with benefit variation by contract.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyLactation Consultations

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2022

Next Review DateMay 11, 2025

Key ActionSubmit claims listing the mother as the patient; claims submitted under the infant (ages 0-12 months) will not be considered for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT 98960Primary covered procedure code

no prior authPrior authorization

licensed IBCLCProvider qualification

mother as patientClaim patient requirement

no cost shareCommercial cost share

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Lactation consultations are covered when provided by qualified providers and billed with appropriate diagnosis codes; reimbursement rules differ by product.

ALL of the following

ANY of the following
- International Board-Certified Lactation Consultant (RLC / IBCLC)
- Physician
Note: Services provided by a Home Care Agency are covered as part of the home care per diem (not separately reimbursed).

ALL of the following

ANY of the following
- CPT 98960 is covered and separately reimbursed when filed with a primary diagnosis from the ICD-10 Diagnosis Code(s) list.
ANY of the following
- CPT 98960 is covered and separately reimbursed with no cost share when filed with a primary diagnosis from the ICD-10 Diagnosis Code(s) list.

ALL of the following

Claims for CPT 98960 must be filed with a primary diagnosis from the ICD-10 Diagnosis Code(s) list to be separately reimbursed (see ICD-10 list).
Claims filed for CPT 98960 with any diagnosis code not found in the ICD-10 list will be covered but not separately reimbursed.

ALL of the following

Claims must be submitted listing the mother as the patient; any claims submitted under the infant (ages 0-12 months) will not be considered for reimbursement.

ALL of the following

A unit is obtained when the midpoint is passed for the time-based code (for example, 16 minutes of face-to-face time is required to bill one 30-minute unit).

ALL of the following

Benefits may vary between groups and contracts; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits/coverage.

Coding and Billing

Covered CPT CodesCPTCovered

98960

Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

Covered ICD-10 Diagnosis Codes (when billing CPT 98960)ICD-10Covered

O92.011-O92.013
O92.019
O92.02-O92.03
O92.111-O92.113
O92.12-O92.13
O92.119
O92.20
O92.29
O92.3
O92.4-O92.5

1–10 of 14

1/2

Time-based Billing Thresholdmixed

unit_midpoint

A unit is obtained when the midpoint is passed (example: 16 minutes required to bill one 30-minute unit).

CPT 98960 - Diagnosis Not on ListCPTNot Covered

98960

If filed with any diagnosis code not in the ICD-10 list, the service will be covered but not separately reimbursed.

Time‑based billing threshold — unit‑midpoint rule

Time‑based unit midpoint ruleA billable unit for time‑based CPT services is obtained when the midpoint of the unit is passed — e.g., 16 minutes of face‑to‑face time to bill one 30‑minute unit (CPT 98960).

Code referencedCPT 98960 (education and training for patient self‑management, each 30 minutes; individual patient).

Documentation requirementFollow CPT coding guidelines for time‑based codes and document face‑to‑face minutes to support units billed.

Provider Actions and Billing Alerts

Prior Authorization

No prior authorization required

Prior authorization is not applicable for lactation consultations.

Billing Rule

List mother as patient on claims

Claims for lactation consultation services must be submitted listing the mother as the patient; claims submitted under the infant (ages 0–12 months) will not be considered for reimbursement.

Submit lactation consultation on a single claim with the mother as the patient.
Do not submit claims using the infant (0–12 months) as the patient — such claims are not payable.

Definitions

IBCLC / RLC — definition and qualification

DefinitionInternational Board‑Certified Lactation Consultant (IBCLC) / Registered Lactation Consultant (RLC): a health professional specializing in clinical management of breastfeeding with formal lactation education and clinical training who has passed an international certification exam and meets continuing education requirements.

Alternate titleAlso referred to as Registered Lactation Consultant (RLC).

Rhode Island licensure eligibilityTo be eligible for Rhode Island licensure, applicants must meet the Rules and Regulations for Licensing of Lactation Consultants (e.g., be ≥18 years old, complete an accredited lactation program, pass the IBCLC exam, and currently hold IBCLC board certification).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyLactation Consultations

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2022

Next Review DateMay 11, 2025

Key ActionSubmit claims listing the mother as the patient; claims submitted under the infant (ages 0-12 months) will not be considered for reimbursement.

SourceLink

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