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documents/medical/werthman/progyny_auth_statement.md

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+---
+type: insurance
+category: patient_confirmation_statement
+person: Yanxin Lu
+date: 2025-08-13
+provider: Center for Male Reproductive Medicine
+source: progyny_auth_statement.pdf
+---
+
+# Progyny Patient Confirmation Statement — Treatment
+
+## Contact Information
+
+**For Providers:**
+auths@progyny.com | 888.461.5062
+
+**For Members:**
+Contact your dedicated Patient Care Advocate
+
+---
+
+## Patient Information
+
+| Field | Value |
+|---|---|
+| Employer | Meta |
+| Progyny Patient Name | Yanxin Lu |
+| Birthdate | 10/17/1989 |
+| Progyny Patient Member ID | 806298980 |
+| Progyny Subscriber Name | Yanxin Lu |
+| DOB | 10/17/1989 |
+| Progyny Subscriber Member ID | 806298980 |
+
+---
+
+## Authorization Details
+
+| Field | Value |
+|---|---|
+| Authorization Number | AUTH-1358040 |
+| Valid From | 08/13/2025 - 11/11/2025 |
+| Practice | Center for Male Reproductive Medicine |
+| Clinic Location | Center for Male Reproductive Medicine (Los Angeles CA) |
+| CPT Code(s) | 99499-25 RU Diagnostics and Workup |
+| Smart Cycle Value | 0.00 |
+
+---
+
+## Notes
+
+Fertility services are administered through Progyny. A list of covered services can be found in the patient's member guide and provider manual. Financial responsibility applies dependent upon patient's medical plan. Any service not included in the authorization for this treatment should be billed to the patient's medical plan unless covered under a separate authorization. The clinic is the guarantor for all in-cycle bloodwork and monitoring services. Please note that outside monitoring is not covered. Call Progyny Provider Relations at 888.461.5062 with any questions.
+
+Transfer cycle authorizations are approved for a single embryo transfer only unless approval from Progyny's Medical Advisory Board is obtained.
+
+**Preimplantation Genetic Testing (PGT) Laboratories:** Please use an approved lab as listed on Progyny.com/labs. Please list Progyny as payer and include the Authorization number for In-Network participating labs.
+
+Authorization ID for PGT-A is the same as the Authorization ID listed on this Patient Confirmation Statement. Authorization ID for PGT-SR or PGT-M must be requested through Provider Relations.
+
+---
+
+## Progyny Claims Submission
+
+| Field | Value |
+|---|---|
+| EDI Payer ID | PROGY |
+| Payer Name | Progyny, Inc. |
+| Claim Address | 505 South Lenola Rd, Suite 231 Moorestown, NJ 08057 |
+
+*Coverage is based upon eligibility at time of service.*