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Vasectomy Procedure Reimbursement: Two simple steps!

Don’t make this too complicated. It is not as difficult as it may seem and there are only two simple steps.

Step 1. Pre-verify your vasectomy coverage before scheduling

We recommend you determine your vasectomy procedure coverage before coming to our office.

This requires that you call your health insurance company, provide them with the medical codes, and they will let you know if vasectomy is a covered procedure and how much they are willing to reimburse you for your vasectomy.

Over 90% of health care insurance companies cover vasectomy procedures. The bigger question is how much will they actually reimburse you (or apply towards your deductible).

Vasectomy Coverage. This term means is your health insurance even willing to pay for your vasectomy? Most plans (over 90%) will offer vasectomy coverage.

Amount owed. This term refers to how much you will need to pay (or how much of your payment they will reimburse you). This depends on 1) what the insurance company thinks a vasectomy should cost, 2) your yearly deductible amount, and 3) how much have you paid towards your yearly deductible.

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 you have met, is the doctor considered a specialist, and is the procedure done in a operating room or office?

If you would like to self-verify vasectomy coverage before you make your vasectomy appointment and also determine what portion you may or may not get reimbursed then follow the 5 steps below.

Five simple steps to verify your 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 your coverage for vasectomy.
Step 3. Provide these codes:

  • 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. Please make sure you are clear 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 it is being done in a doctor's office.

Step 4. Inform them Dr. Monteith is designated a specialist and the procedure is performed in the doctor’s office. If they ask place of treatment code = 11.
Step 5. Have them clarify the following:

  • Is vasectomy covered?
  • How much will you be reimbursed for your vasectomy? You may have to 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 (1) you have vasectomy coverage and (2) how much you can expect to be reimbursed after you submit your Member Claim Form.

Step 2. Obtain reimbursement after vasectomy completed

After your vasectomy procedure is completed, you will need to submit the information we provide you (receipt and billing information) and a completed Member Claim Form to your health insurance company.

Here are the steps required by your health insurance company for vasectomy procedure reimbursement.

Step 1. Have your vasectomy completed by our office.
Step 2. Pay for vasectomy on the day of service and we will provide you with a receipt and medical billing report.
Step 3. Obtain a "Member Claim Form" from the website of your health insurance company.
Step 4. Complete the Member Claim form with the information we provide you.
Step 5. Submit Member Claim form to your health insurance company for reimbursement. You will need to include the billing receipt we provide you. This billing receipt has the appropriate codes and medical information required to support  your completed Member Claim Form. 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.

If the following information is too much...we can walk you through it at the time of your visit with us.

VASECTOMY: Single Visit (Most patients will use this form)

Most men will choose to have a vasectomy under local anesthesia completed in a single visit. If you have your vasectomy done under local anesthesia during a single office visit then complete your Member Claim form like this sample form:

Sample Completed Member Claim Form: Single Visit Vasectomy

You will also need to provide your health insurance company the receipt provided by our office. Your form will need to have the same dates and codes as our receipt.

SEDATION VASECTOMY: Single Visit

If you have Sedation Vasectomy performed during a single visit then complete your Member Claim form like this sample form:

Sample Completed Member Claim Form: Single Visit Sedation Vasectomy

You will also need to provide your health insurance company the receipt provided by our office. Your form will need to have the same dates and codes as our receipt.

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.

Although we have a fully functioning operating room in our office, health insurance companies typically only reimburse for procedures done in a hospital or ambulatory care surgical center setting.

Without getting too complicated, your health insurance company's reluctance to reimburse is more of a political/licensing issue... not a patient safety issue.

We recommend you submit a Member Claim Form even if they tell you that you don't have coverage or you may not be fully reimbursed... because any amount paid to our office should contribute towards your yearly deductible and they need a record of that payment.

***You want to get credit for your payment. Don't let your health insurance company off the hook! Remember the average health care CEO salary in 2018 was $18 million dollars!***

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:

Sample Completed Member Claim Form: Consultation Visit Only

VASECTOMY PROCEDURE: After 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 has been completed:

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.

Although we have a fully functioning operating room in our office, health insurance companies typically only reimburse for procedures done in a hospital or ambulatory care surgical center setting.

Without getting too complicated, your health insurance company's reluctance to reimburse is more of a political/licensing issue... not a patient safety issue.

You will need to get the real Member Claim Form from the website of your health insurance company. The form can only be submitted with the receipts we provide you and after your procedure has been completed.

If you have any questions then contact your health insurance company and they will be able to assist you. Member Claim forms are commonly submitted by health insurance members.

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Ask Us A Question!

Your questions about our services will be answered directly and promptly by our staff or Dr. Monteith. We will not respond to general medical questions or if you are a patient of another practice and are contacting us because you are not getting answers from your physician.

If you have been a patient at our center and have specific questions about your medical care you should contact the staff directly at (919) 977-5060.

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