Birthing Center Reimbursement
TRICARE-authorized freestanding or hospital-affiliated birthing centers that provide outpatient maternity care to TRICARE beneficiaries are reimbursed based on the lower of TRICARE’s established all-inclusive rate (network discounts may apply) or billed charges.
The all-inclusive rate includes services usually associated with a normal pregnancy and childbirth:
- certified nurse-midwife professional services,
- physician professional services (includes physician services for routine consultation when a certified nurse-midwife is the attending professional),
- birth assistant,
- laboratory studies,
- prenatal management,
- labor management,
- postpartum management,
- newborn care,
- and use of the facility.
The initial complete newborn examination by a pediatrician is not included in the birthing center all-inclusive fee. It will be cost-shared as part of the maternity episode when performed within 72 hours of delivery.
Claims from birthing centers shall be submitted on a UB-04 claim form and subsequently processed as outpatient hospital claims using revenue code 724 and 59400 as the CPT procedure code with either Place of Service code “22” or “25”. The cost-share amount for birthing center claims is calculated using the ambulatory surgery cost-share formula.
Birthing centers that only provide part of the professional or facility services because the beneficiary moves and gets the remaining services elsewhere will only be reimbursed for that actual services provided as part of the all-inclusive rate.
For more information on birthing center reimbursement, please refer to the TRICARE Reimbursement Manual, Chapter 10, Section 1, paragraph 3.3. Additional maternity benefit information is located under our Benefits A–Z.