One of the big questions I get asked is if I hire a birthkeeper or doula, will my insurance company cover her fees?  And if so, how do I go about it?  This is a very good question because if you’re olanning for a home birth understand most of the costs are out-of-pocket and it can be a sudden cost if pregnancy was not intentional.

Insurance companies are finally recognising that doulas can actually help lower costs, thanks to a number of studies.  There was a fairly large study involving 15,288 women that found having a birth keeper/doula present at a woman’s birth can shorten her labor time as well as lower the risk of costly interventions such as cesarean sections, instrumental usage and epidural anaesthesia. Women allocated to continuous support were more likely to have a spontaneous vaginal birth.  They also found it was good for baby too. The study found that the babies were less likely to have low APGAR scores and lower rates of NICU admittance. 

What you need to know!

There are twenty+ insurance companies that have begun paying for doula services. You will have to call your insurance company to see if they participate. And if they do, you will have to find out if they’ll cover all the expenses or just part of it. 

Anthem Blue Cross – I found this PDF regarding birthkeeper/Doula care for Anthem.  It contained all the required Billing codes as well as all the requirements.  Here is another useful link.   Anthem requires a Doula Services Benefit Recommendation Form be filled out by your healthcare provider.  Here is the link to the form.

Medi-Cal also has new requirements. According to The Department of Health Care Services (DHCS) “As a preventive benefit, birthkeeper/doula services require a written recommendation from a physician or other licensed practitioner of the healing arts.” For more information click on Doula Services Frequently Asked Questions. Here is more information for the State of California Medi-Cal Doula Services Recommendation. I’m stuck

There is a special CPT code (CPT stands for Current Procedural Terminology, and is a copyright of the American Medical Association) covering birth keeper/doula services. Here is the special CPT code:  (Anthem has different codes)  Here are some more links: Anthem Doula Program provider guide

Below we’ll provide you with the service and matching codes (make sure to like, comment and share this article if you found it a useful resource)

• 99499 – Birth doula for Evaluation and Management Services/Labor Support.
• 99501 and/or 99502 – Postpartum doula services
• S9443 – Lactation classes, non-physician provider, per session
  (Note: S-codes are often recognised by private insurers but not Medicaid/Medicare.)
• 99404 – Preventive medicine counselling, individual, approximately 45 minutes
  (Often used for prenatal/postnatal education, including lactation counselling.)
• 99241–99245 – Office consultation for a new or established patient
  (If services are under or supervised by a licensed provider)
• 98960 – Education and training for patient self-management, individual, 30 minutes
  (May apply when educating on breastfeeding techniques and infant care.)
• 59400 – Routine obstetric care including antepartum care, vaginal delivery, and postpartum care
• 59409 – Vaginal delivery only (no antepartum/postpartum)
• 59410 – Vaginal delivery including postpartum care
• 99501 – Home visit for postnatal care
• 99502 – Home visit for newborn care
• 99211–99215 – Evaluation and management office or home visits (established patient (Depending on complexity and documentation, sometimes used by midwives.)

This is important! Your birth keeper/doula must have a NPI (National Provider Identification) number in order for you to apply for a reimbursement. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign NPI numbers.  

Join Rooted in Wisdom Business Sisters to receive 1-1 guidance on applying for a NPI if you’re a birth keeper/doula: Sign up here: Rooted in Wisdom Business

How to Request Insurance Reimbursement for Birth Keeper/Doula Service

1. Pay your birthkeeper/doula in full.
2. Get an invoice from her which includes the following information:
3. The birthkeeper/doula’s name and address.
4. Her social security number/taxpayer ID number or NPI number.
5. The date and location services were provided.
6. The CPT code for the services provided.

• Birth doula (99499), this is a nonspecific code described as “Evaluation and Management Services” and can be applied to the prenatal, birth and postpartum periods when coupled with the appropriate diagnosis codes. 
• Postpartum doula services (99501 and/or 99502/and or 59430) According to this “the CPT code 59430 is also an unspecific code described as “General Postpartum Care” and can be applied to the postpartum period when coupled with the appropriate diagnosis code.”
• A diagnosis code. The diagnosis code typically used for prenatal and labor support is V22.2 “Pregnant State Incidental.” The diagnosis code typically used for postpartum is V24.2 “Routine Postpartum Follow Up.” 
• The doula’s signature.
• Submit the invoice with a claim form to your insurance company.  The standard claim form that is usually used is (HCFA-1500).  However your provider may have a different form and they should be able to provide you with the necessary form.
• Within four weeks, expect a letter telling you either that:
• They need more information before they can process your claim.
• This is not a covered expense.
• Ask your Doula to send you the following: A copy of her certification (if she is certified) Other credentials or relevant training. A letter detailing her training and experience and what she did for you (see example letter I wrote for my client below) 
• If possible, ask your obstetrician or midwife for a letter explaining why a doula helped you, was necessary, or saved the insurance company money. (Did you have a high-risk pregnancy? Did the doula’s suggestions appear to prevent complications or help your labor to progress more quickly? Did the doula’s presence decrease your need for expensive pain medications?)
• Write a letter explaining why you felt the need for a doula and how you believe the doula was beneficial to your health.
• Submit to your insurance company: the doula’s letter and credentials, the letter from the doctor and your cover letter.
• If they refuse it, write a letter to Health Services requesting that they review the claim, as you feel it was a cost-cutting measure and they should cover the cost.
• Follow up by telephone if necessary.
• If they refuse, write a letter to the CEO explaining why you feel that doula care should be a covered expense. They may not pay your claim, but they will consider it for the future. (Kelli Way, ICCE, CD(DONA) 1998. Reprinted with permission.)

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