Fertility Revenue Cycle Management Built for IVF Practices
A fertility practice generates 10–25 billable service lines per IVF cycle, routes claims to fertility benefit managers most billers have never heard of, and navigates 21 state mandates with different rules. General RCM companies aren't built for this. We are.
Why Fertility RCM Requires Specialists
Fertility billing sits at the intersection of reproductive medicine coding, insurance mandate law, embryology lab billing, and fertility benefit manager networks — a combination general RCM companies are not equipped to navigate.
Fertility benefit carve-outs
Progyny, WINFertility, and Maven Clinic manage fertility benefits separately from the primary insurer. Submitting to the wrong payer produces immediate denials with no appeal path. We identify carve-out coverage at eligibility verification — before the first claim.
Multi-phase cycle billing
A single IVF cycle spans stimulation monitoring, retrieval (58970), fertilization (89250), extended culture (89272), biopsy (89290), cryopreservation (89258), and transfer (58974/58976) — often across 2–3 weeks and multiple dates of service. Each phase needs its own claim, documentation, and coding.
Dual NPI claim tracks
Physician services (58xxx, 76830) bill under the provider NPI; embryology lab services (89xxx) bill under the laboratory NPI or separate tax ID. Mixing these tracks produces duplicate-claim edits and coordination-of-benefits denials that take weeks to untangle.
State mandate variability
21 states mandate fertility coverage, each with different cycle limits, diagnosis requirements, S-code obligations, and employer exemptions. New Jersey, Illinois, and Massachusetts have among the most comprehensive mandates; Texas and Florida have none. Patient coverage depends on both the plan and the state where it was issued.
Authorization per cycle component
REI prior authorization is not a single approval — it is a separate authorization for IVF retrieval, embryo transfer, FET, PGT, donor sperm/egg, and sperm retrieval. Each has its own medical necessity criteria, expiration window, and documentation requirement. One missed auth can deny a $6,000 claim.
ICD-10 specificity requirements
Payers require the most specific diagnosis available: female infertility by etiology (N97.0–N97.9), male factor (N46.x), PCOS (E28.2), POI (E28.31), structural anomalies (Q50.x). Using unspecified codes triggers medical necessity reviews and underpayments across all claim types.
Our 8-Stage Fertility RCM Process
Every stage is handled by staff who work exclusively in fertility — not generalists who occasionally see an IVF claim.
Eligibility & Benefits Verification
We verify active coverage, fertility benefit riders, deductibles, OOP maximums, and lifetime cycle limits before every treatment cycle — not just at the first visit. Progyny, WINFertility, and other carve-out benefits are identified upfront so claims route to the correct payer from day one.
Prior Authorization Management
IVF, FET, PGT, donor cycles, and sperm retrieval each require individual authorizations that expire independently. We submit, track, and renew every auth — with payer-specific medical necessity documentation — so no claim is submitted without active coverage.
CPT & ICD-10 Coding
Our AAPC-certified coders assign the correct procedure codes (58970, 58974, 58976, 89250, 89258, 89290, 76830, and more) and diagnosis codes (N97.x, N46.x, E28.2, Z31.x) for every service line. Multi-phase IVF cycles are unbundled correctly across retrieval, fertilization, culture, and transfer dates.
Claim Submission & Scrubbing
Claims are scrubbed against payer-specific edits before submission — catching modifier errors, NPI mismatches, and bundling conflicts that produce avoidable denials. Physician and embryology lab claims are coordinated to submit on the correct NPI/tax ID track.
Payment Posting & Reconciliation
ERA/EOB auto-posting is reconciled against expected reimbursement schedules. Underpayments are flagged automatically. Every fertility cycle is closed only when all service lines across the full treatment episode are accounted for.
Denial Management & Appeals
Denials are worked within 48 hours of receipt. We distinguish medical necessity denials (clinical appeal) from technical denials (corrected claim) and authorization issues (peer-to-peer coordination). Our fertility-specific denial library covers every major payer denial reason code.
Patient Financial Services
Benefit explanations, cost-of-care estimates, payment plan setup, and patient statement management — delivered in plain language. We reduce front-desk burden while improving collection rates on patient-responsible balances.
Reporting & Analytics
Monthly dashboards show collection rate by CPT code, denial rate by payer, AR aging, days-to-pay, and first-pass resolution rate. You see exactly where revenue is leaking — and what we are doing to recover it.
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Related Services
See how EasyRCM improved collections for a New England REI group practice.
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