Provider Notice issued 12/19/2024

The Department of Healthcare and Family Services (HFS) received approval from the Federal Centers for Medicare & Medicaid Services (CMS) to provide coverage for lactation consultant services required under Public Act 102-0665. This coverage applies to the Medicaid fee-for-service (FFS) program and the managed care organizations (MCOs). In this notice, unless otherwise specified, the term “lactation consultants” encompasses all certified lactation consultants, certified lactation counselors, and certified lactation specialists.  

Certification

Lactation consultants must obtain a certificate from their certifying board prior to completing the Medicaid enrollment process with HFS. International Board-Certified Lactation Consultants (IBCLCs) must be certified by the International Board of Lactation Consultant Examiners.  Certified Lactation Counselors (CLCs) must be certified by the Academy of Lactation Policy and Practice, Inc. Certified Lactation Specialists (CLSs) must be certified by the Lactation Education Consultants.

The uploaded certificate must contain a unique certification number tied to the lactation consultant, with a certificate effective date and expiration date. The certificate must be uploaded during the provider enrollment process with HFS. When lactation consultants recertify their credentials, they must submit proof of recertification to HFS.

Provider Enrollment

Lactation consultant services are reimbursable to certified lactation consultants enrolled in the Illinois Medicaid Program Advanced Cloud Technology (IMPACT) provider enrollment system. Lactation consultants should review the IMPACT Account Activation Instructions for New External IMPACT Users.

In IMPACT, a lactation consultant may select an Enrollment Type of either:

1.)   Rendering/Servicing Provider– An individual provider who will be rendering services to Medicaid customers but will not be submitting claims directly to the State for reimbursement. Enrolling as a Rendering provider requires that you associate with a Group Practice or Facility, Agency, Organization (FAO) as a billing provider in the IMPACT system and would not allow you to bill for yourself.

2.)   Regular Individual Sole Proprietor – A provider that owns his/her own practice. A Sole Proprietor may receive payments directly or associate to Billing Providers and/or Billing Agents. If you enroll as a Sole Proprietor, you can still also associate with a Group Practice or FAO as your Billing Provider(s) and they may bill on your behalf, but this is optional. You can use this enrollment option to work as part of an organization and/or bill for yourself.

Lactation consultants must have a National Provider Identifier (NPI) in order to enroll. Information about obtaining an NPI is located on the CMS website.     

Note Regarding Advanced Practice Registered Nurses: If you are an advanced practice registered nurse who is also an IBCLC, CLC, or CLS, you can bill using Evaluation and Management codes and do not need to enroll under the new provider type.

Note Regarding Clinics: Federally Qualified Health Centers, Rural Health Clinics, and Encounter Rate Clinics will be allowed to bill practitioner claims (instead of medical encounters). For the services listed below, the service must be billed under the enrolled, rendering lactation consultant’s NPI with payment directed to the clinic/center’s corporate NPI.

Procedure Codes, Modifiers, and Rates

Standing Recommendation

The State of Illinois has issued a standing recommendation for lactation consultant services. When lactation consultants document the services they deliver, they must note in their documentation that they either (1) used the standing recommendation or (2) used a recommendation from a specific licensed physician, physician assistant (PA), or advanced practice registered nurse (APRN).

This documentation is for audit purposes and to meet the federal requirement that preventive services provided by the lactation consultant provider type be recommended by a licensed provider. The information will not go on the claim submitted for reimbursement.

The standing recommendation cannot be used by IBCLCs, CLCs, or CLSs if breastfeeding is contraindicated by any drug use or health condition, as specified in the standing recommendation.

Claim Submission

Claim Format

   · Lactation consultant services are billed electronically on the 837 Professional transaction. Information regarding electronic 837P transactions may be found in the Chapter 300 Companion Guide. Claims may also be submitted via direct data entry within the MEDI system. 

   ·  Lactation consultant services must be billed under the birthing person’s recipient identification number (RIN), or the child’s RIN if the birthing person is not Medicaid eligible.

Taxonomy Code
· Taxonomy code for lactation services: 174N00000X

Telehealth

• The telehealth delivery method is allowable for all services, utilizing modifier GT (Via Audio and Video Telecommunications Systems) or 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system) and place of service 02 (Telehealth Provided Other than in Patient’s Home) or 10 (Telehealth Provided in Patient’s Home), as applicable.

Fee schedule

· More detail regarding the billable procedures is contained in the Lactation Consultant Fee Schedule on the Reimbursements page of the HFS website.

Medicaid Provider Educational Materials and Webinars for Lactation Consultants

The Medicaid Technical Assistance Center (MTAC), in partnership with HFS, has prepared enhanced Medicaid onboarding educational materials and support to aid lactation consultants in the enrollment process. This includes a Medicaid provider overview specifically for lactation consultants, how to obtain a National Provider Identifier (NPI), and how to enroll in IMPACT, the Illinois Medicaid provider enrollment system.

Please visit the MTAC Learning Center to register for an MTAC Learning Center account to access the calendar of training dates, times, and registration links. Lactation consultants may also reach MTAC for technical assistance support at mtac.maternalhealth@uillinois.edu.

Questions regarding this notice, or requests to schedule a MEDI training, may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or the appropriate MCO.                                                      

Kelly Cunningham, Administrator
Division of Medical Programs