TRICARE allows for certified labor doulas, lactation consultants and lactation counselors – currently excluded as TRICARE-authorized provider types under the TRICARE benefit – to provide reimbursable care to TRICARE beneficiaries under its Childbirth and Breastfeeding Support Demonstration. This is a five-year demonstration that started on Jan. 1, 2022.
- Lactation counselors have received specialized training to aid in breastfeeding and infant nutrition from breastmilk, and generally provide breastfeeding counseling to support normal lactation and breastfeeding parents of healthy, full-term infants.
- Lactation consultants have the highest level of breastfeeding training and may be necessary when complex problems surrounding breastfeeding arise.
- Labor doulas, sometimes referred to as birth doulas, aid a birthing parent during the birthing process. They provide support for the birthing parent prior to, during and after labor. Labor doulas are not medical personnel and do not provide medical services, such as examination of the cervix or prescription of medications, and do not give medical advice.
Please review the demonstration details below. We also offer a printable fact sheet for your use and answers to freqently asked questions at the bottom of this page.
Benefits
- Up to six sessions of breastfeeding (lactation) counseling from a certified lactation consultant or counselor (six total, whether rendered under the demonstration or the TRICARE basic benefit by a TRICARE-authorized provider such as a physician, physician assistant, nurse practitioner, certified nurse midwife, registered nurse, outpatient hospital or clinic).
- Up to six visits by a certified labor doula (CLD) services before or after giving birth for pregnant beneficiaries who are at least 20 weeks and under the care of a TRICARE-authorized provider (for example, obstetrician, certified nurse midwife, etc.), as well as one continuous labor support encounter during the birth event.
This demonstration will not be offered at a military hospitals and clinics.
Costs
Cost-shares, copayments and deductibles don’t apply to covered breastfeeding/lactation counseling services. (See Point of Service note under "Referrals" below.)
Referrals
TRICARE beneficiaries do not need a referral for services under the demonstration. For TRICARE Prime beneficiaries, Point of Service charges may apply for care received by non-network providers without a referral.
Provider Directory
Locate participating network and non-network providers in our Childbirth & Breastfeeding Support Demonstration Directory.
Important: If you are an existing network provider (for example, a physician’s assistant) who performs services as a certified labor doula, lactation counselor or lactation consultant, let us know so we can update your listing in our Network Provider Directory! Send us an updated roster with your secondary specialty information.
These are the taxonomies:
- Doula – 374J00000X
- Lactation Consultant
- Non-RN – 174N00000X
- RN – 163WL0100X
- Lactation Counselor – 174400000X (will show as "Specialist" in the NPI registry)
Our directories will be updated by April 1, 2022.
Provider Participation/Joining Our Network
Lactation counselors, lactation consultants and labor doulas must meet the certification requirements outlined in the TRICARE Operations Manual, Chapter 18, Section 11 in order to be reimbursed under the demonstration. See "Provider Requirements" below.
- Providers interested in joining the TRICARE West Region network may contact us for additional information.
- Existing network groups who have these provider types should notify us via an updated roster (see taxonomies above).
- Non-network applications are available on our Non-Network Certification Applications page.
Provider Types/Requirements
Lactation counselors, lactation consultants and labor doulas must meet the certification requirements outlined in the TRICARE Operations Manual, Chapter 18, Section 11 in order to be reimbursed under the demonstration. Providers interested in joining HNFS’ TRICARE West Region network may contact us for additional information (additional network requirements apply). Non-network applications are available on our “Non-Network Provider” forms page.
Lactation consultants, lactation counselors and certified labor doulas must:
- Be at least 18 years old.
- Have/maintain a current adult, child, and infant CPR certification.
- Have a National Provider Identification (NPI) number.
- Have malpractice insurance in amount of $200k/$600k
- Not have any current Medicare or Medicaid sanctions
- Not have any unexplained gaps in work history for the most recent five (5) years
- Be licensed/certified by one of the acceptable boards as noted in the table below (if offered within the state, must also have state license/certification)
Certified labor doulas must also:
- Have attended a minimum of 24 education hours to include:
- the physiology of labor;
- labor doula training;
- antepartum doula training; and
- postpartum doula training.
- Have attended one or more breastfeeding courses.
- Have attended one or more childbirth classes.
- Not have obtained education/experience during the CLD’s own pregnancy/childbirth or the childbirth of an immediate family member.
Acceptable Boards
| Provider Type |
Board |
|---|
| Lactation Counselor |
- ALPP-certified as Certified Lactation Counselor
|
| Lactation Consultant |
- IBCLE-certified as an International Board-Certified Lactation Consultant; or
- ALPP-certified as an Advanced Lactation Consultant or Advanced Nurse Lactation Consultant
|
Certified Labor Doula
|
- The CLD holds a current certification as a CLD, certified doula or similar perinatal certification (postpartum doula certification by itself does not qualify), obtained within the last three years from one of the following organizations:
Postpartum doula certification by itself does not qualify.
Additional Requirements (must sign attestation):
- Provided continuous in-person childbirth support for at least three childbirths, with a minimum of 15 hours over the three childbirths
- At least two of the three births were a vaginal birth
- Provided antepartum and postpartum support for at least one birth
|
Reimbursement
- Individual lactation counseling sessions: CPT® 99401 (15 min.); 99402 (30 min.); 99403 (45 min.); 99404 (60 min.)
- Group lactation consulting: CPT 99411 (30 min.) and 99412 (60 min.)
- Antepartum and postpartum visits: CPT 99509 (untimed, up to six combined antepartum and postpartum visits)
- Continuous labor support visits: CPT 59899 (untimed, one per birth event)
Certified labor doula services not personally performed will not be reimbursed.
The provider’s National Provider Identification (NPI) number must be on all claims. To learn more about NPIs, visit our NPI page. Also see "Taxonomies" below.
View current rates at www.health.mil/rates.
Frequently Asked Questions
Q. Why do I need to show proof of malpractice insurance to participate as a provider under the CBSD?
A. Lactation counselors, lactation consultants and labor doulas must meet the certification requirements outlined in the TRICARE Operations Manual (TOM), Chapter 18, Section 11 to be reimbursed under the demonstration. To be a TRICARE network provider, you also must meet HNFS and URAC credentialing requirements, which include proof of malpractice insurance in the amount of $200K/$600K.
Q: Will I need a National Provider Identification Number (NPI) to bill for services?
A: Yes. All providers must have an NPI to bill for services under the CBSD. The NPI on the claim determines where we will send payment. This requirement is outlined in the TOM, Chapter 18, Section 11.
Q: How can I apply for an NPI?
A: NPIs are generated by a system called the National Plan and Provider Enumeration System (NPPES) and issued by the U.S. Department of Health and Human Services (HHS) through the Centers for Medicare and Medicaid Services (CMS). 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 the TOM, Chapter 18, Section 11 in order to be reimbursed under the CBSD.
Q: Where can I find current reimbursement rates for services allowed under the CBSD?
A: Find current rates at https://www.health.mil/rates > CMAC > Procedure Pricing. You must select your locality or ZIP code.
Q. What is balance billing?
A. Balance billing occurs when a provider bills a TRICARE beneficiary for any amount more than the CHAMPUS maximum allowable charge (CMAC), also referred to as TRICARE maximum allowable charge (TMAC), after the claim has processed. This practice is limited by law. TRICARE prohibits the practice of balance billing.
- TRICARE network providers agree to be paid the lesser of the CMAC or your contracted rate and may not bill patients for any amount more than the CMAC.
- Participating non-network providers accept assignment and agree to accept the CMAC as payment in full. They may not bill patients for any amount more than the CMAC.
- Non-participating non-network providers do not accept assignment and do not agree to accept the CMAC as payment in full. Per federal balance billing laws, they may not balance bill the beneficiary more than 115% of the allowable charge.
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. Yes. 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.
Q. How do I submit a claim to TRICARE?
A. Visit our Claims tab to learn how to submit claims, check claim status, and review billing tips and rates and reimbursement. XPressClaim is an online electronic claims system recommended for providers who submit fewer than 150 TRICARE claims per month.
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