See our Breast Pumps and Supplies page for benefit information and approval requirements.
Prescription Requirement
The prescription must be included when submitting claims for breast pumps and supplies (when applicable) to HNFS. This prescription must specify the type of breast pump and indicate the number of weeks the beneficiary is pregnant or the age of the infant.
- In lieu of creating a specific prescription form, the referring provider can complete our Breast Pump and Supplies Prescription form and submit it with the claim.
- A certificate of medical necessity is not required unless you exceed the quantity limits listed below.
Billing and Reimbursement
To be accurately reimbursed, providers billing for breast pump supplies using unlisted Healthcare Common Procedure Coding System (HCPCS) codes A9900 or A9999 also must include the following modifiers. These modifiers let HNFS know specifically which supplies were provided to the beneficiary.
| Supply Type |
Modifier |
Quantity Limits (Without Prescription) |
|---|
| Replacement valves/membranes |
XG |
12 every 12 months (6 pairs/units) |
| Replacement breast milk storage bags |
XH* |
100 individual bags every 30 days |
| Replacement nipple shields |
XD |
2 sets (2 shields per set) every birthing event |
| Supplemental nursing system |
XN |
1 every birthing event |
| Breast pump kit |
XR |
1 every birthing event |
*HNFS will only accept procedure code A4287 (dates of service on or after Jan. 1, 2024) or K1005 (dates of service before Jan. 1, 2024) on claims for breast milk storage bags. Claims with the unlisted HCPCS code A9900 or A9999 and modifier XH will be denied. Note: This does not pertain to other breast pump supplies.
Reimbursement will be the lesser of billed charges, negotiated rates or the Centers for Medicare and Medicaid Services durable medical equipment, prosthetics, orthotics and medical supplies fee schedule.
- Hospital-grade breast pumps are customarily rented. Once the rental cost has reached the purchase price, the provider must consider the item purchased and may not continue to bill rental charges.
- TRICARE covers standard shipping and handling charges for purchases made online.
View our claims page for more details on submitting claims.
| Supply Type |
Modifier |
Quantity Limits (Without Prescription) |
|---|
| Replacement valves/membranes |
XG |
12 every 12 months (1 unit = a set of 2 valves/membranes) |
| Replacement breast milk storage bags |
XH |
90 individual bags every 30 days |
| Replacement nipple shields |
XD |
2 sets (2 shields per set) every birthing event |
| Supplemental nursing system |
XN |
1 every birthing event |
| Breast pump kit |
XR |
1 every birthing event |
HNFS has coordinated with Humana Military, the TRICARE East Region contractor, to implement these same billing guidelines, as we recognize some breast pump supply companies operate on a national level.
Reimbursement will be the lesser of billed charges, negotiated rates or the Centers for Medicare and Medicaid Services durable medical equipment, prosthetics, orthotics and medical supplies fee schedule.
- Hospital-grade breast pumps are customarily rented. Once the rental cost has reached the purchase price, the provider must consider the item purchased and may not continue to bill rental charges.
- TRICARE covers standard shipping and handling charges for purchases made online.
View our claims page for more details on submitting claims.
| Supply Type |
Modifier |
Quantity Limits (Without Prescription) |
|---|
| Replacement valves/membranes |
XG |
12 every 12 months (1 unit = a set of 2 valves/membranes) |
| Replacement breast milk storage bags |
XH |
90 individual bags every 30 days |
| Replacement nipple shields |
XD |
2 sets (2 shields per set) every birthing event |
| Supplemental nursing system |
XN |
1 every birthing event |
| Breast pump kit |
XR |
1 every birthing event |
HNFS has coordinated with Humana Military, the TRICARE East Region contractor, to implement these same billing guidelines, as we recognize some breast pump supply companies operate on a national level.
Reimbursement will be the lesser of billed charges, negotiated rates or the Centers for Medicare and Medicaid Services durable medical equipment, prosthetics, orthotics and medical supplies fee schedule.
- Hospital-grade breast pumps are customarily rented. Once the rental cost has reached the purchase price, the provider must consider the item purchased and may not continue to bill rental charges.
- TRICARE covers standard shipping and handling charges for purchases made online.
View our claims page for more details on submitting claims.
