Maternity ultrasounds are covered separately from the maternity care benefit. TRICARE has specific requirements for covering and reimbursing maternity ultrasound services.
Maternity ultrasounds are covered when needed to:
- Estimate gestational age.
- Evaluate fetal growth.
- Conduct a biophysical evaluation for fetal well being when there is a chronic maternal disease such as insulin dependent diabetes mellitus, hypertension, systemic lupus, congenital heart disease, chronic renal disease, hyperthyroidism, prior pregnancy with unexplained fetal demise, multiple gestations, post-term pregnancy after 41 weeks, intrauterine growth retardation, oligo- or polyhydramnios, preeclampsia, decreased fetal movement or isoimmunization.
- Evaluate a suspected ectopic pregnancy.
- Define the cause of vaginal bleeding.
- Diagnose or evaluate multiple births.
- Determine heart rate not detectable by Doppler when it should be heard or there is suspicion of fetal demise, making it necessary to confirm cardiac activity.
- Evaluate maternal pelvic masses or uterine abnormalities.
- Evaluate suspected hydatidiform mole.
- Evaluate the fetus’ condition in late registrants for prenatal care.
TRICARE does not cover maternity ultrasounds to determine the sex of the baby.
Note: The professional and technical components of medically necessary fetal ultrasounds are covered outside the maternity global fee.
Billing for Medically Necessary Ultrasounds
For rendering providers billing with a supervision of a normal pregnancy diagnosis, a secondary diagnosis is required to establish medical necessity for a diagnostic fetal ultrasound performed during a normal pregnancy. Otherwise, the claim will not be reimbursed.
Additionally, primary prenatal care providers who refer patients out to receive an ultrasound need to provide the medical diagnosis (reason for the ultrasound) to ensure proper billing by the rendering provider.
Always include these codes when you bill.
Billing the Beneficiary for Ultrasounds
If the TRICARE beneficiary and the rendering ultrasound provider agree to perform an ultrasound that does not have a valid medical indication, the ultrasound provider may only bill the beneficiary directly under the following circumstances:
- Network providers must require the beneficiary to complete a Request for Non-Covered Services form (or equivalent) prior to the service being rendered. This form confirms the beneficiary has agreed to pay in full for the ultrasound.
The general release of a liability form used by most provider offices does not relieve the provider of responsibility under TRICARE and as such, the use of the Request for Non-Covered Services form is strongly recommended.
The provider should retain this form with the beneficiary’s file and refer to it, if necessary, for beneficiary billing purposes. If the form is not completed in advance of the ultrasound, the beneficiary is “held harmless” and cannot be billed.
- Non-network providers should inform the beneficiary she is financially responsible for the ultrasound. A written document identifying the beneficiary’s agreement to pay for the ultrasound is recommended. Non-network providers can also use the Request for Non-Covered Services form to document the agreement prior to the service.