Insurance Info for General Infertility Patients

In order to protect your confidentiality, and to maintain the Foundation’s low-administrative costs, we do not accept credit cards and we do no third party billing. You will receive an invoice and insurance forms with your kit.

Many of our tests are covered by insurance. The amounts reimbursed for each test vary widely between insurance companies. In your kit you will receive all the forms necesary to submit your claim to your insurance company.

For your convenience you may download the forms you will need to submit to your insurance company here. You will need to submit three forms: the HICF, the Test Descriptors, and your Invoice from Bedford Research Foundation (you will receive this in your kit, or you may call to request a copy).

1. The only form that you will need to fill-out is the Health Insurance Claim Form (HICF). Start by downloading the appropriate form in PDF format.

Next download the Form Instructions in PDF format.

Form Instructions

Complete sections 1 – 13. If applicable, have your doctor fill in 14-18.

For the Live Semen Transport Kit, Prostatitis Kit, Vasectomy Check Kit, and Fixed Semen Cytology Kit use the Health Insurance Claim Form marked Male Infertility at the top. Write in the date you sent (or dropped-off) your kit in section 24 A, numbers 1-3. For the Live Semen Transport Kit, the total for column F is already filled in section 28. All other kits please refer to your invoice for this amount and for the numbers in the column marked “CPT/HCPCS”. Since you will have already paid the Foundation for your tests, fill the same amount into section 29 and put a zero in section 30.

For blood tests, use the Health Insurance Claim Form marked Hormone Tests at the top. Refer to the line items marked Estradiol, Progresterone, LH, or hCG on your invoice to fill in sections 24 A-F.

For section 24 A, use the Date of Specimen from your invoice.
For section 24 D, use the number (CPT code) next to Estradiol Progresterone, LH, or hCG on your invoice (leave the Modifier column empty).
For section 24 E, fill in the Diagnosis Code 628.9 for each blood test.
For section 24 F, use the appropriate Unit Price from your invoice.

Fill in the total for column F in section 28. Since you will have already paid the Foundation for your tests, fill the same amount into section 29 and put a zero in section 30.

Please note that some insurance companies must receive typed forms, therefore the PDF forms are editable. You should be able to enter all of your information while viewing the form in adobe acrobat. If you are unable to do this, you may need to download the latest version of acrobat, please visit the adobe website www.adobe.com.

2. Download Test Descriptors in PDF Format, simply include this form with your insurance claim.

3. Bedford Research Foundation Invoice (you will receive this in your kit, or you may call to request a copy). Send this invoice, with the Test Descriptors and your complete Health Insurance Claim Form (HICF) to your insurance company.

Bedford Research Foundation does not guarantee that any part of your bill will be covered by insurance. All proceeds from testing go to research.

Financial Aid for Infertility

www.feeplan.com (Capital One)