How to Fill Out and Submit the Ambetter Breast Pump Request Form

The Ambetter breast pump request form is a short PDF that collects your member ID, prescribing provider’s details, due date or delivery date, diagnosis code, and preferred pump type, and it is used mainly when the order comes through your doctor’s office rather than a durable medical equipment (DME) supplier. Most Ambetter members never fill it out themselves. Ambetter contracts with several DME providers who verify coverage, obtain the prescription, and submit paperwork on your behalf, which is faster than handling the form directly. If your state’s plan does require the form, you can download it from the provider resources section of your state’s Ambetter website or request a copy by calling the member services number on the back of your ID card.¹

Ambetter covers at least one breast pump per pregnancy at zero cost-sharing, with no copay, deductible, or coinsurance.² The base-level double electric pump should always be free; some suppliers offer higher-end models for an upgrade fee, which is optional.

When You Can Order

The form specifies you must be within 30 days of your expected due date or have delivered within the past six months.¹ Some DME suppliers let you start the qualification process earlier, as soon as you have a confirmed due date, but the pump itself ships closer to that window. Starting a few weeks before the 30-day mark gives the supplier time to verify coverage and chase down any missing information before you need the equipment.

What to Have Ready Before You Start

Gather these items first, whether you order through a DME supplier or submit the form directly:

Your Ambetter member ID number from the front of your insurance card. If you are listed as a dependent, you also need the primary policyholder’s name.
Your expected due date or delivery date. This confirms you fall within the eligibility window.
A prescription from your OB-GYN, midwife, or primary care provider. The order should state that you need a breast pump and include ICD-10-CM diagnosis code Z39.1, which identifies the encounter as care for a lactating mother.³
The prescribing provider’s name and 10-digit National Provider Identifier (NPI). The provider’s office can give you this, or you can look it up in the CMS NPPES registry.
The provider’s phone number, so the claims team can call if anything on the request needs clarification.

Many DME suppliers will contact your doctor and obtain the prescription for you if you give them the office’s details. If you already have a written prescription in hand, submission moves faster.

Ordering Through a DME Supplier (the Easier Path)

Ambetter lists several contracted DME providers that handle breast pumps, including Aeroflow, Byram, Edgepark, CCS Medical, Edwards, J&B Medical, Nextra Health, and Shield Healthcare.⁴ Confirm the supplier you choose participates in your specific state plan before placing the order, because network participation varies.

The process looks similar across suppliers. You go to the supplier’s website or call them, enter your insurance details and due date, and the supplier verifies your Ambetter coverage electronically. Once you are confirmed eligible, you choose from the pump models your plan covers. The supplier submits paperwork to Ambetter, coordinates the prescription with your doctor if needed, and ships the pump to your home after approval. Through a supplier like Aeroflow, the online qualification step takes about a minute. You enter your name, date of birth, member ID, due date, and state, and the supplier handles the rest.⁵

Filling Out the Form Directly

Some state plans use a standalone PDF request form, particularly when the order is placed by a provider’s office. The Washington state Ambetter form (from Coordinated Care) is a representative example and is available through the provider resources page.¹ Your state’s version may be laid out differently, but the required fields are consistent.

The form asks for:

Your member ID
The policyholder’s name
The prescribing provider’s name and NPI
The Z39.1 diagnosis code
Your expected due date or delivery date
Your preferred pump type

Fill in every field. Blanks slow processing. Submit the completed form along with the prescription through the method your plan specifies: uploading through a secure portal, faxing to the claims department, or having your doctor’s office transmit it electronically. Referrals placed outside normal business hours are processed the next business day.¹

If you cannot find the form on your state’s site or are unsure which submission method applies, call the member services number on the back of your ID card. The representative can walk you through the process or route you to a contracted DME supplier.⁶

Replacement Parts

Federal preventive services guidelines require coverage of pump parts and maintenance for the duration of breastfeeding while you stay enrolled.⁷ Ambetter plans generally cover functional components like tubing, adapters, bottles and caps, and breast shields. Baby scales, batteries, cleaning supplies, nipple creams, hands-free pumping garments, nursing bras and pads, and travel accessories typically fall outside coverage. Breast milk storage bags sit in a gray area because updated federal guidelines list them as covered breastfeeding supplies, but individual plan formularies vary. Call your plan before ordering replacements through a DME supplier if you want to confirm what counts.

Hospital-Grade Rentals Work Differently

The standard request form and process apply to a personal double electric pump. A hospital-grade rental is a separate track. Insurers generally consider one medically necessary when a newborn cannot nurse directly, for example, due to prematurity, a condition like cleft palate, or a neurological disorder that interferes with feeding. A hospital stay separating mother and baby after discharge is another common qualifying scenario. Hospital-grade rentals require a separate authorization, with initial approval often covering around three months. Your provider submits updated documentation to extend the rental. Ask your doctor to include the clinical details in the prescription so the authorization is complete on the first submission.

If Your Request Is Denied

The most common reasons a request stalls are missing fields on the form, an incomplete prescription, ordering outside the eligibility window, or picking a supplier that does not participate in your state’s Ambetter network. Confirm every field is filled in and that the prescription includes the Z39.1 code and your provider’s NPI before submitting.

If Ambetter denies the request, you can appeal. The process involves a first-level appeal, and if that fails, a second-level appeal within 90 days of the first denial notice. Call member services for the specific instructions and deadlines that apply to your state plan. For a denial based on medical necessity, particularly for a hospital-grade rental, a letter of medical necessity from your doctor submitted with the appeal strengthens the case.

1
Ambetter Health. Ambetter Breast Pump Request Form
2
HealthCare.gov. Breastfeeding Benefits
3
ICD10Data. ICD-10-CM Diagnosis Code Z39.1 – Encounter for Care and Examination of Lactating Mother
4
Ambetter Health. Durable Medical Equipment (DME) Providers
5
Aeroflow Breastpumps. Qualify for a Free Breast Pump Through Insurance
6
Ambetter Health. Maternity and Family Planning
7
Health Resources and Services Administration. Women’s Preventive Services Guidelines