Benefits/Policies
Q. Why are 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 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).
Provider Requirements
Q. Are postpartum 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 the 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 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 the 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 TOM, Chapter 18, Section 11 and additional HNFS credentialing requirements.
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 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 (CPT code 99509).
Q. When billing for the continuous labor support (CPT code 59899), 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: Are there any place of service restrictions when rendering care under the CBSD?
A: A lactation provider may render and bill for services in a variety of places of service. Certified labor doulas are restricted to the patient’s home for antepartum and postpartum care (CPT code 99509) and a hospital, birthing center or patient’s home for the continuous labor support (CPT code 59899). Refer to the Claims and Reimbursement section of the CBSD page 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 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.
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 (CPT code).
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.
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 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. The TRICARE Maximum Allowable Charge (CMAC) is based on the location of the provider.
Q. What is balance billing?
A. Find more information on our Balance Billing page.
