Insurance Coverage Worksheet:
This quote may not guarantee benefits or coverage. You and CNY can be misquoted benefit information.
Insurance Company: ______________________ Policy/Member ID #: _____________________
Who is covered under the policy: ☐ self ☐ partner ☐ both Who is the policyholder? ☐ self ☐ partner ☐ I am a dependent under ___________(name) ______(date of birth)
*Is this your ONLY active medical insurance? ☐ YES ☐ NO *If no, is this policy PRIMARY or SECONDARY. If you have two insurance policies, you must provide our office with both the primary and secondary insurance information. Failure to supply the office with your primary insurance will result in full denials by your secondary insurance and patient responsibility.
Is a Referral Required from my Primary Care Physician? ☐ YES ☐ NO
What is my Deductible: $___________
How much of my deductible have I met this year? $ _________ as of (date) ___ /___ /___
Do I have an ‘out of pocket maximum’: $___________
Do I have a Co -Pay per visit: $_______ for Specialist Office Visit
$______ for bloodwork/ labs
$_______ for radiology/ultrasounds
Do I have to pay a % of my diagnostic testing and office visit(s) once my deductible is met? %
Is there a preferred laboratory I should go to for bloodwork? ☐ Lab Corp ☐ Quest ☐ Other:_________
*If your insurance requires use of specific lab, you must notify our office in advance of each bloodwork appointment. CNY Fertility routinely sends bloodwork to LabCorp. If LabCorp is not in your insurance network, you may have additional costs.
Does my policy have an Infertility Age Limit? ☐ YES _____________ ☐ NO
Is the CNY Fertility location of choice, ‘IN NETWORK’ with my policy? ☐ YES ☐ NO
• If no, do I have out of network benefits? ☐ YES ☐ NO
If I do have out -of-network benefits, do I need to pay a higher percentage of my care? ☐ Yes ___ % ☐ No
While speaking with your insurance company , they may ask for a billing (CPT procedure) code.
This is a 5-digit code used by the insurance company to determine if something is covered. We have included those CPT codes for services below. Please use this as a guide to explore your coverage.
Below are the commonly used diagnosis codes for testing and/or during a cycle.
• Common diagnosis code used for DIAGNOSTIC/PRECONCEPTION TESTING orders:
o Z31.41 Procreative Management/Testing or N97.9 Female Infertility
• Diagnosis code used for all monitoring services with IUI/IVF/FET cycles and with all IUI/IVF/FET procedures:
o Z31.83 Encounter for ART procedure cycle
Preconception Blood Testing:
Blood Type & Rh Antibody Screen (86900) CBC w/o Diff (85027) CMP (80053)
Anti-Mullerian Hormone/AMH (82166) Rubella IgG (86762) Varicella (86787)
Prolactin (84146) Testosterone (84403) Vitamin D (82306) RPR (86592)
Hepatitis B Surface Antigen (87340) Hepatitis C Antibody (86803) HIV ½ Antibody (87389)
TSH (84443)
Preconception Genetic Testing:
Expanded Carrier Screening – Beacon Expanded Carrier Screening PLUS Panel, offered in our CNY office, will be sent to LabCorp. Please be sure this lab is network with your insurance. This panel may not be covered by most insurance plans. (CPT Code: 81443) Karyotype (88262) Chromosome (88230)
Is prior authorization required for preconception genetic testing? ☐ YES ☐ NO
Additional Preconception/Fertility Testing:
HSG (dye test): (CPT Codes: 58340, 74740, 76831) Covered? ☐ YES ☐ NO
*Prior authorization or Referral Required? ☐ YES ☐ NO
Semen Analysis for male partner: (CPT Codes: 89310/89320) Covered? ☐ YES ☐ NO
*Prior authorization or Referral Required? ☐ YES ☐ NO
*Male partner must be listed on the policy, to be billable to the insurance.
Treatment Coverage/ART (Assisted Reproductive Technology) Coverage:
Do I have coverage for IUI – Artificial Insemination? Details/Limits: ___________________________
CPT Codes: 58322, 89260, 89261, 89353 (If applicable: Sperm Thaw 89353)
Preauthorization Required? ☐ YES ☐ NO
IVF – In-Vitro Fertilization?
Details/Limits: _____________________________
*What requirements must be met for IVF coverage to be considered? (Minimum # of IUI’s for example)
Preauthorization Required? ☐ YES ☐ NO
CPT Codes: 58970, 58974, 76705, 76948, 89250, 89272, 89280, 89281, 89253, 89254, 89255, 89258, 89342, 89261
*Assisted Hatching (89253) & Embryo Cryopreservation (89258) with IVF - Covered? ☐ YES ☐ NO
Biopsy of Embryo(s) for genetic testing with IVF?
(Biopsy performed by CNY Fertility. Genetic Testing by outside laboratory, Cooper Genomics)
Biopsy for PGD CPT Code: 89290, 89291
Genetic testing- CPT Code: 81228/99000 PGT -A, 88299 PGT -M
Preauthorization Required? ☐ YES ☐ NO
Preauthorization Required? ☐ YES ☐ NO
Details/Limits:
*If patient and/or partner have previously undergone voluntary sterilization (tubes tied or vasectomy):
Will Infertility coverage be available following voluntary sterilization? ☐ YES ☐ NO
Coverage for a FET – Frozen Embryo Transfer? (CPT Codes: 76857, 76830, 89352, 89253, 89255, 58974, 58976)
Coverage Details/Limits: _________________________________________________
Preauthorization Required? ☐ YES ☐ NO
*Assisted Hatching with FET (CPT: 89253) Covered? ☐ YES ☐ NO
Storage of frozen sperm/egg(s)/embryo(s)/testicular tissue: Annual storage fee is $600.00 when not covered by insurance and will be billed to you by Embryo Options/CNY Cryo Inc, upon that sample being received and/or frozen at a CNY office.
Embryo Storage (89342)
Sperm Storage (89343)
Egg/Oocyte Storage (89346)
Tissue Storage (89354)
Do I have coverage for fertility medications: ☐ Yes ☐ No
Covered? ☐ YES ☐ NO
Covered? ☐ YES ☐ NO
Covered? ☐ YES ☐ NO
Covered? ☐ YES ☐ NO
Do fertility medications require a prior authorization: ☐ Yes ☐ No
(example of fertility medications: Gonal F/Folllistim, Cetrotide/Ganirelix, HCG/Pregnyl, Lupron) Is there a preferred pharmacy for fertility medications, per this insurance?
DATE/TIME of call: ____________ Insurance Representative Name: ___________________
REFERENCE # FOR YOUR CALL : ____________________________
*Name of Rep and Reference # are needed, should you not be quoted accurate information