Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 01|01|2022 POLICY LAST REVIEWED: 07|01|2024

OVERVIEW
A doula is a paraprofessional who provides advice, information, emotional support, guidance, and physical comfort, etc. to pregnant persons, birth parent(s), partner(s), family, etc. before, during, and after pregnancy.

This policy applies to BCBSRI Commercial Products only. This policy does not apply to Medicare Advantage Plans, as doula services are not covered for Medicare Advantage members or for members of Blue Cross and/or Blue Shield Plans nationally e.g., BlueCard members.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION
Not applicable

POLICY STATEMENT Commercial Products Doulas must submit a formal credentialing application prior to rendering services to any BCBSRI member to be considered in-network. The doula must be certified by the Rhode Island Certification Board (RICB) prior to credentialing.

Doula services are covered as follows per each pregnancy.
Note: Doula services can be self-initiated by a member through self-screening e.g., a positive pregnancy test at home or through a healthcare provider referral:
 *Prenatal and Postnatal visits (up to the first 12 months postpartum)
 Labor and delivery – 1 encounter/unit of billing
o 1 encounter/unit of billing for labor and delivery services is covered regardless of the duration/hours of the birthing process or for support whenever and however the pregnancy ends. o If more than one doula provides services for Labor and Delivery, the doula who provided the services at the initiation at Labor and Delivery shall be the billing provider for Labor and Delivery services e.g., 1 unit of billing. The second doula that provides services shall not file a claim, nor be reimbursed for their services by BCBSRI. It is expected that the initial doula that attends the Labor and Delivery and who submits a claim will coordinate with the second doula in terms of their reimbursement for their portion of the delivery for which they provided services.

COVERAGE Doula services are available through BCBSRI for Commercial members only. There is no member cost share for doula services. This includes but is not limited to; all deductibles (both HSA compatible and non- HSA compatible deductible plans) as well as any coinsurance and/or copayments that a member may have under their plan.

Payment Policy | Doula Maternity Services

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

For BCBSRI self-funded employer groups, doula services are offered upon group renewal. Please note that self-funded employer groups/benefit plans hold the ability to elect to include or exclude doula services. Please remember to check benefits for each member seeking to obtain doula services.

Please note this Policy is only applicable to BCBSRI Commercial members, members who receive their healthcare coverage through BCBSRI. It does not apply to members of Blue Cross and/or Blue Shield Plans nationally/BlueCard members. Doulas looking to provide services to non-BCBSRI members should call the number on the back of the member’s ID card to identify if the member has doula benefits.

BACKGROUND A doula is a person who provides emotional and physical and other support during pregnancy, childbirth and after delivery/or at the end of pregnancy, and during the postpartum period. A certified doula has participated in applicable training program(s) in how to assist pregnant persons, birth parent(s), partner(s), family, etc., prior to, during and after pregnancy.

Doulas can perform different roles, depending on and directed by the needs of the pregnant person, birth parent(s), partner(s), family, etc. Elements of doula services may include: The doula accompanies their client, provides emotional and physical support, suggests comfort measures, and provides support and suggestions for the partner. Whenever possible, the doula provides pre- and post- partum emotional support, including explanation and discussion of practices and procedures, and assistance in acquiring the knowledge necessary for the client to make informed decisions about their own care. The postpartum doula cares for their client and their family in their home in the first few weeks to months following the birth. The doula provides non-medical support and companionship, assists with newborn care and sibling adjustment, meal preparation and household organization. The doula offers evidence-based information on newborn feeding, emotional and physical recovery from childbirth and other issues related to the postpartum period and can make referrals if necessary.

While labor and delivery of a live birth is the hopeful outcome, not all pregnant persons deliver a live birth. The postpartum period up to 12 months is the most critical time whether a live birth occurs or not. Doula services pose an effective interdisciplinary solution for families during this timeframe. If a member’s pregnancy does not result in a live birth, the remaining allowance for perinatal doula services can be used toward postpartum and/or bereavement supports.

CODING Commercial Products The following CPT code and modifiers should be used by participating perinatal doula providers:

S9445 Patient education, not otherwise classified, non-physician provider, individual, per session *

A doula visit is considered a visit of at least 60 minutes. Providers shall bill one (1) unit of service for every hour in which doula services are provided. Providers should not report or submit claims for services that are less than 60 minutes. Members are allowed up to 15 visits for prenatal and postnatal services and one labor and delivery for in-network Doulas.

Please review BCBSRI’s fee schedule for allowances for each service. Modifiers

Use Modifier FP for prenatal services:
FP Service provided as part of family planning program

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Use Modifier XU for attendance at the delivery:
XU Unusual nonoverlapping service, the use of a service that is distinct because it does not overlap usual

components of the main service

Use Modifier TH for postnatal services:
TH Obstetrical treatment/services, prenatal or postpartum

Note: BCBSRI requires all claims to be submitted with the Modifiers above e.g., FP, XU, TH in the first or primary modifier field on all claims.

Use Modifier 95 for audio-visual telemedicine services in the secondary modifier field on all claims. 95 Synchronous telemedicine service rendered via a real-time interactive audio and video

telecommunications system.

If the above coding is not followed, BCBSRI will not be able to identify the services as Doula services and the claim will not reimburse under the correct benefit.

Note: As a reminder, according to our Timely Filing Guidelines, claims must be submitted within 180 days from the date of service of your claim.
Place of Service BCBSRI allows for prenatal and postnatal visits via telemedicine e.g., conducted via telephone only as well as audio-visual telemedicine visits.

All telemedicine services, regardless if performed via telephone only or audio-visual, must be billed with the following Place of Service:
Place of Service (POS) 02: The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.

Place of Service (POS) 10: The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology

All other services should use an appropriate place of service code e.g., 12-Home, 11-Office, 22- Outpatient Hospital, etc.

RELATED POLICIES Lactation Consultations

PUBLISHED Provider Update, November 2023 Provider Update, December 2021

REFERENCES

1. 1. What is a Doula? What services do they provide? (DONA International) Having a Doula - What are the Benefits? | American Pregnancy Association
2. 6/29/2021 Public Notice Of Proposed Amendment To Rhode Island Medicaid State Plan, State Of Rhode Island Executive Office Of Health And Human Services
3. State of Rhode Island In General Assembly January Session, A.D. 2021. 2021 -- H 5929 Substitute A

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate

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500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.