Benefits/Policies
Q. Why are labor doula services not covered at military hospitals and clinics?
A. Per TRICARE Operations Manual (TOM), Chapter 18, Section 11, military hospital and clinic care is excluded for labor doula services.
Q. How do I identify a TRICARE patient for the CBSD?
A. You can verify patient eligibility online (log in required), through the self-service tools at 1-844-866-WEST (1-844-866-9378), or via electronic data interchange (EDI).
Q. Where can I learn more about the updates to labor doula certification and Phase 1 and Phase 2 reimbursement?
A. We've updated our CBSD web pages to include information on these updates. You can also read our news article, download our fact sheet, and attend a provider webinar.
Provider Requirements
Q. Are postpartum labor doula support providers covered under the CBSD?
A. Postpartum-only doula providers are not covered. A doula must be a certified labor doula but can be dual certified for certified labor and postpartum.
Q. Why do I need to show proof of professional liability insurance to participate as a provider under the CBSD?
A. Lactation counselors, lactation consultants and labor doulas must meet the certification requirements outlined in TOM, Chapter 18, Section 11 to be reimbursed under the CBSD. To be a TRICARE network provider, you also must meet HNFS and URAC credentialing requirements, which include proof of professional liability insurance in the amount of $200K/$600K.
Q. How long does it take to be approved as a provider?
A. It can take up to 90 days to credential a new provider once all completed information is received. Non-network provider certification takes approximately 30 days once we’ve received a completed application. Missing requirements will delay processing. Be sure to include the required documents with your network participation or credentialing application.
Q. What is the difference between someone being independently contracted vs. having employers?
A. A sole practitioner bills with a Type 1 National Provider Identifier (NPI) and their Social Security number (SSN) or Employee Identification Number (EIN). A group bills with a Type 2 NPI and a Tax Identification Number or EIN. A group owner could have one or many other practitioners. Providers who are contracted under the group are also the rendering providers. All providers who render care with an intent to bill TRICARE must be certified and/or credentialed.
Q: How can I apply for an NPI?
A: NPIs are generated by the National Plan and Provider Enumeration System (NPPES) and issued by the U.S. Department of Health and Human Services through the Centers for Medicare & Medicaid Services. Learn more at https://nppes.cms.hhs.gov.
Q: What if my state does not offer a license or certification?
A: Labor doulas, lactation consultants and lactation counselors must meet the certification requirements outlined in TOM, Chapter 18, Section 11 in order to be reimbursed under the CBSD as a non-network provider. To be a network provider, you must meet the requirements in the TOM and additional HNFS credentialing requirements. Also see CBSD Provider Participation.
Referrals/Accessing care
Q. If there are no in-network providers, is a referral still needed for patients to see a non-network provider?
A. TRICARE Prime-enrolled beneficiaries need referrals to see non-network providers, even if there aren't any network providers available. Patients enrolled in TRICARE Select do not require referrals. For information and resources on how to submit referrals, visit our How to Submit and Authorization or Referral Request page. When submitting your online request, please note the following request type profiles:
- P180 – Doula services
- P159 – Lactation support
Q. What can a TRICARE patient do if there are no TRICARE-authorized CBSD providers available, but the patient found a doula or lactation provider willing to render care?
A.The TRICARE patient may contact HNFS at 1-844-866-WEST (9378) and nominate the provider for participation. The prospective provider may also email ChildbirthSupport_Providers@hnfs.com directly for participation inquiries. In either case, if the patient choses to receive care from a provider prior to certification/participation, the claim(s) may be denied if the provider does not meet the requirements of the CBSD and TOM, Chapter 18, Section 11.
Claims/Reimbursement
Q. How do I submit a claim to TRICARE?
A. Visit our Claims Submission page for details.
Q. How can I check the status of a claim?
A. You can check status online or through our automated self-service option at 1-844-866-WEST (9378).
Q. If I miss the birth, can I still bill for postpartum care?
A. You may bill for the services you personally render. This includes postpartum care (Phase 1 CPT code 99509 or Phase 2 T1033).
Q. When billing for the continuous labor support (CPT code 59899 or T1033), is the date of service the entire admit-to-discharge date range or just the date of delivery?
A. The date of service is the actual date of birth.
Q. My patient began labor on one date and didn't deliver until the next day. How do I bill that?
A. Continuous labor support should only have one date of service. This is the date the patient actually delivers.
Q: Are there any place of service restrictions when rendering care under the CBSD?
A: Lactation providers may render and bill for services in a variety of places of service.
Certified labor doulas (CLD) are restricted to the patient’s home for antepartum and postpartum care (Phase 1 CPT code 99509 or Phase 2 T1032) and a hospital, birthing center or patient’s home for the continuous labor support (Phase 1 CPT code 59899 or Phase 2 T1033).
Refer to CBSD Claims and Reimbursement for additional information.
Q. If I am TRICARE-certified as both a labor doula and lactation counselor, can I bill for these two services for the same day?
A. If you are credentialed and approved for both labor doula and lactation services, you may bill for both services but not on the same date of service. Keep in mind, the diagnosis (ICD-10 code) may be different for each service. Let us know if you have acquired an additional specialty by emailing us at ChildbirthSupport_Providers@hnfs.com. Be sure to attach a copy of your certificate for your specialty.
Q. As a lactation provider, I spent over 60 minutes with the lactating parent. May I bill with multiple service lines/CPT codes to equal the amount of time I was with the patient on the same date of service?
A. No. The lactation support CPT codes are timed with a maximum of one session allowed per date of service. The maximum amount of time billable for one date of service is 60 minutes.
Q. I provided services covered under the CBSD to a TRICARE beneficiary but have not joined the TRICARE West Region network nor submitted a non-network application. Can the beneficiary submit her own claim to TRICARE?
A. The beneficiary can submit a claim for reimbursement. We offer instructions for beneficiary-submitted claims on our website. Upon receipt of the claim, we will reach out to certify you as a non-network provider. Keep in mind, if you do not meet TOM, Chapter 18, Section 11 requirements we will deny the claim and the beneficiary will be liable for the billed amount. For labor doula services, Phase 1 reimbursement would apply to any beneficiary-submitted claims. Beneficiary-submitted claims for labor doula services will not be allowed after Dec. 31, 2024.
Q. If I miss the birth because it was too fast or the client failed to call me, can I still file a claim?
A. TRICARE will only reimburse providers who actually render the care. Any labor doula who is stepping in for another also must be TRICARE certified to be eligible for reimbursement.
Q. Is reimbursement under TRICARE based on where the patient lives or where the provider is located?
A. If the place of service is a hospital or office, reimbursement rates are based on the location of the provider. If the place of service is the patient's home, then rates are based on the patient's home address. Find current rates at www.health.mil/rates:
Q. What do I do if a beneficiary has other health insurance (OHI) besides TRICARE?
A. A beneficiary's OHI must be used before TRICARE with the exception of Medicaid and a few other plan coverages. Refer to How TRICARE Works with Other Health Insurance for more details.
Q. What is balance billing?
A. Find more information on our Balance Billing page.
