Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 12|06|2011 POLICY LAST UPDATED: 09|21|2022 OVERVIEW This policy documents Blue Cross & Blue Shield’s (BCBSRI) coverage and payment guidelines related to home births. MEDICAL CRITERIA Not applicable. PRIOR AUTHORIZATION
Not applicable. POLICY STATEMENT Medicare Advantage Plans and Commercial Products • Credentialing: Participating providers must notify BCBSRI and be credentialed specifically for home births and carry liability insurance which must include coverage for home births. • Coverage:

1. The following services are covered: a. Home Births services are covered, including routine antenatal, delivery, and postpartum care
2. All of the following services are not covered and are member liability: a. Additional prenatal counseling sessions or prenatal evaluation/management services specifically related to home birth. b. Any equipment, supplies including emergency kits, and/or services specifically due to home birth. c. Charges related to prolonged personal attendance. d. Home modifications. e. Standby Services such as: supplies, equipment, support personnel, or ambulance.
3. Member transfer to facility for delivery: a. Home birth provider will be paid for attending labor in the home prior to transfer but not for attendance in the ambulance; and b. Delivery services will be paid only to the provider who delivers the child; and c. If during attendance at labor it is determined that the patient must be transferred to a facility and another clinician performs the delivery service, BCBSRI will cover up to one E/M service in the home and up to 3 additional hours of prolonged services with direct care if provided. • Billing:
4. All global maternity policies apply.
5. The following provider services are not payable by BCBSRI and are not member liability: a. Provider may not bill prenatal care when another provider is also billing prenatal services for the same period; and b. No additional prenatal Evaluation and Management services related to high-risk pregnancies for home birth patients will be covered as home births are expected to be uncomplicated. Payment Policy | Home Births

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

COVERAGE Benefits may vary. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, Subscriber Agreement for applicable maternity benefits/coverage.

BACKGROUND Not applicable.

CODING Not applicable.

RELATED POLICIES High Risk Pregnancy Services Doula Maternity Services

PUBLISHED Provider Update, November 2022 Provider Update, April 2020 Provider Update, December 2018 Provider Update, February 2018

REFERENCES

1. The American College of Obstetricians and Gynecologists. The American College of Obstetricians and Gynecologists Issues Opinion on Planned Home Births. April 2017. Accessed on February 3, 2020: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric- Practice/Planned-Home-Birth

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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 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. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS