Will Health Insurance Cover Your Vasectomy
Determining health insurance coverage for His Choice vasectomy?
Most health insurance plans will cover a vasectomy procedure.
If a health insurance plan does not cover vasectomy it is usually a religious based plan or a very inexpensive health insurance plan with a high annual deductible.
We recommend you contact your health insurance company and ask them two questions:
- Question #1: Does your policy provide coverage for vasectomy?
- Question #2: How much will they reimburse you if you pay out of pocket?
Many people will simply ask if vasectomy is a ‘covered procedure? This is not the best question to ask.
Most plans will ‘cover’ vasectomy. Just because you are ‘covered’ does not mean they will pay for your procedure.
This is a more complicated question to answer and it depends three things:
- Do you have a deductible and how much of your deductible have you paid for in that year?
- Have paid your full deductible amount in year you are trying to have your vasectomy?
- How much more do you have to pay to meet your deductible in the year you are trying to have a vasectomy?
What is your health insurance deductible?
What you really want to know is how much will your health insurance pay towards your vasectomy?
What is paid by you or the health insurance company depends on the amount of your deductible and how much you have paid towards your deductible in a given year. Unfortunately, deductible amounts are a moving target and they reset to zero at the beginning of every year.
If you do not have a deductible, then they may pay the full amount for your vasectomy (if they cover vasectomy).
If you have a high deductible, for example $5,000, then you are responsible for the first $5,000 of your health care in a given year. Only after you have paid $5,000 will your insurance company then start paying for your treatments.
Your deductible is what makes this more complicated. Deductible amounts reset every year depending on how much you have paid towards your health care in a given year.
- If it is the beginning of the year and you have not paid towards your deductible then you will pay up to the amount of your deductible before health insurance begins to cover your cost.
- Once you have meet your annual deductible then your health insurance will cover your health care cost for the remainder of the year.
- Deductibles are determined annually and they usually reset to zero paid at the beginning of every year.
Most young healthy people who do not frequently see physicians do not pay much of anything towards health care during an average year and this is why they select lower cost, high deducible plans. If you are one of those healthy people with a high deductible health plan, then you are going to pay the full amount of your vasectomy procedure.
You want to ask your health insurance company if vasectomy is a covered procedure?
You also want to ask your health insurance company how much will they pay towards your procedure?
What you are really asking when you inquire about coverage is do they see vasectomy as a worthwhile procedure?
For example, they may offer coverage for vasectomy but they may not provide coverage for infertility or cosmetic treatments. Most plans (over 90%) will offer vasectomy coverage. Occasionally, religious based plans will not cover vasectomy.
How much will you owe?
The amount owed is often the more complicated question and it depends on the quality of your plan, do you have a yearly deductible, how much of the yearly deductible have you met, is the doctor a specialist, and is the procedure done in an operating room or office?
Five simple steps to verify vasectomy coverage
Step 1. Call your health insurance customer care agent using the number on your health insurance card.
Step 2. Inform the agent you are calling to determine if you have coverage for a vasectomy procedure.
Step 3. Provide the agent with the codes of the procedure you are trying to obtain.
Use the codes below. Over 99% of patients will be obtaining vasectomy with local anesthesia. This is our single visit vasectomy procedure.
- Vasectomy with local anesthesia: Vasectomy office visit code 99205, Diagnosis code Z30.2, and Vasectomy procedure code 55250
- Sedation Vasectomy: Vasectomy office visit code 99205, Diagnosis code Z30.2, and Vasectomy procedure code 55250. They also need to know anesthesia code of 00921QX-P1.
Make sure you inform the agent this is being done in a doctor’s office.
They may tell you “Yes…it is covered.” because they automatically assume the procedure is being done in a hospital operating room. They need to understand the procedure is being done in a doctor’s office.
Step 4. Inform them the doctor is designated as a specialist and the procedure is performed in the doctor’s office. The place of treatment code = 11.
Some health insurances will not pay or will pay much less if you go to an ‘out of network’ doctor. You will have to ask them if His Choice is considered ‘in-network’ or ‘out-of network’.
Unfortunately, if a doctor does not accept health insurance, most health insurance plans will consider these doctors as being out of network.
Step 5. Have them clarify the following:
- Is vasectomy covered?
- How much will you be reimbursed for your vasectomy?
You should inform them the doctor does not accept health insurance and you will be submitting a Member Claim Form after the procedure has been completed.
Using the information above your health insurance agent should be able to tell you if you have vasectomy coverage and how much you can expect to be reimbursed after you submit your Member Claim Form.
How to obtain reimbursement for your His Choice vasectomy procedure?
After your vasectomy procedure has been completed, you will need to request payment from your health insurance company.
You will need a receipt that you have paid for the procedure and an office superbill with the procedure codes. We will provide you with this information after your vasectomy procedure has been completed.
You will also need to send a completed Member Claim Form to your health insurance company.
Step 1. Have your vasectomy.
Step 2. Pay for vasectomy on the day of service and we will provide you with a receipt, office superbill, and your office records.
Step 3. Obtain a “Member Claim Form” from the website of your health insurance company.
Step 4. Complete the Member Claim form. Use the links below to provide you with guidance on how to complete your Member Claim form.
Step 5. Submit your Member Claim form to your health insurance company for reimbursement. You will need to include the office superbill with the appropriate codes and medical information required to support your completed Member Claim Form.
All health insurance companies will require the physician’s tax ID number. You will get this number on your office superbill. The number is the EIN which stands from Employer Identification number. The EIN is the tax ID number. They are the same.
Most health insurance companies require the form be sent by mail. Some may allow electronic transmission, email, fax, or up-load to an on-line portal.
Below are sample completed Member Claim forms with the correct billing codes demonstrating how the form should be completed to obtain vasectomy procedure reimbursement from your health insurance company.
The form will be completed differently depending on if you have 1 or 2 office visits.
Will Insurance Cover Your Vasectomy Procedure? Find Out In 2 Simple Steps!
Five steps required to verify vasectomy coverage.
Step 1. Call your health insurance customer care agent using the number on your health insurance card.
Step 2. Inform the agent you are trying to determine if you have coverage for vasectomy.
Step 3. Provide the agent with the codes of the procedure you are trying to obtain:
- Vasectomy with local anesthesia: Vasectomy office visit code 99205, Diagnosis code Z30.2, and Vasectomy procedure code 55250
Step 4. Inform them the doctor is designated as a specialist and the procedure is performed in the doctor’s office. The place of treatment code = 11.
Some health insurances will not pay you or will pay you much less if you go to an ‘out of network’ doctor.
You will have to ask them if His Choice is considered ‘in-network’ or ‘out-of network’.
Unfortunately, if a doctor does not accept health insurance, most health insurance plans will consider these doctors as being out of network.
Step 5. Have them clarify the following:
Is vasectomy covered? How much will you be reimbursed for your vasectomy?
You should inform them the doctor does not accept health insurance and you will be submitting a Member Claim Form after the procedure has been completed.
Using the information above your health insurance agent should be able to tell you if you have vasectomy coverage and how much you can expect to be reimbursed after you submit your Member Claim Form.
How to obtain reimbursement for your His Choice vasectomy procedure?
After your vasectomy procedure has been completed, you will need to request payment from your health insurance company.
- You will need the following:
A payment receipt from our office. - An office superbill with the procedure codes. We will provide you with this information.
- A Member Claim Form. You can get this from your health insurance company.
Step 1. Pay for vasectomy on the day of service. We will provide you a receipt and superbill.
Step 2. Obtain a “Member Claim Form” from the website of your health insurance company.
Step 3. Complete the Member Claim form.
Step 4. Submit your Member Claim form to your health insurance company for reimbursement. You will need to include your payment receipt and office superbill that we provide you.
Submit the completed Member Claim form with a copy of the receipt and office superbill.
Below are sample completed Member Claim forms with the correct billing codes demonstrating how the form should be completed to obtain vasectomy procedure reimbursement from your health insurance company.
The form will be completed differently depending on if you have 1 or 2 office visits.
The sections below contain examples of completed Member Claim forms. Complete your member clam form like the examples and submit to your health insurance company for reimbursement.
Most patients will be submitting the claim for vasectomy performed during a single office visit.
Tax ID Number is the EIN
Your health insurance company will require the doctor’s tax ID number when you submit your Member Claim Form. You will get this number on your office superbill.
The number on the superbill is listed as the EIN, which stands from “Employer Identification number”. The EIN is the tax ID number.
Click on the sections below for more information.
Vasectomy performed during a single office
Most patients will use this form. If you have your vasectomy done under local anesthesia during a single office visit then complete your Member Claim form like this sample form demonstrates:
Sample Completed Member Claim Form: Single Visit Vasectomy
Single visit sedation vasectomy
If you have Sedation Vasectomy performed during a single visit then complete your Member Claim form like this sample form demonstrates:
Sample Completed Member Claim Form: Single Visit Sedation Vasectomy
Consultation visit only
If you choose to have a consultation visit before your procedure (either with local anesthesia or Sedation Vasectomy) then complete your Member Claim form like this sample form demonstrates:
Sample Completed Member Claim Form: Consultation Visit Only
Vasectomy procedure after a consultation visit
If you had a consultation first and then returned on a separate date for a procedure under local anesthesia then complete your form as this sample form demonstrates:
Sample Completed Member Claim Form For Vasectomy After Consultation
Technically, you should be able to submit the codes for the two visits on one Member Claim form. You would need to indicate the consult and the procedure were done on separate dates when you complete the form.
You would also need to include the two separate receipts provided by our office. The receipts need to have dates and codes that exactly match your completed Member Claim form.
Sedation vasectomy after a consultation visit
If you had a consultation first and then returned on a separate date for a Sedation Vasectomy procedure then complete your Member Claim form as this sample form has been completed:
Sample Completed Member Claim Form For Sedation Vasectomy Procedure After Consultation Completed
Technically, you should be able to submit the codes for the two visits on one form…you would need to indicate the consult and procedure were done on separate dates when you complete the form.
You would also need to include the two separate receipts provided by our office. The receipts need to have dates and codes that match your Member Claim form.
Please be advised your health insurance may be reluctant to reimburse you for anesthesia procedures done outside of hospital setting. They may also object to paying the facility fee.
If you have any questions then contact your health insurance company and they will be able to assist you.
