Nurse Midwife Program — Coverage Criteria for Certified Nurse Midwives
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Rules governing participation, covered services, billing, reimbursement, and record requirements for certified nurse midwives participating in the Alabama Medicaid program.
No material clinical or coverage changes in this revision.
Covered Services & Criteria
Covered Maternity and Related Services
Covered maternity services and billing rules
Visits covered by the global code are not counted against the recipient's annual physician office visit limit. For group practices, services rendered by members of the group are considered services rendered by a single provider.
Antepartum-only services billed with 59425/59426 do not count against the recipient's annual office visit benefit limits; office visit codes will count against annual limits.
Exception: if the midwife's first and only encounter is delivery ('walk-in' patient), the midwife may bill for a hospital admission (history and physical) in addition to delivery charges.
Family planning services performed by the delivering provider on the day of the postpartum exam or within five (5) days of the postpartum exam are noncovered as separate services because they are included in the postpartum exam. If the provider did not perform the delivery but provides postpartum care, family planning services rendered within five (5) days of the postpartum exam are also noncovered.
Family Planning and Well-Woman Care
Family planning and gynecological services
Diaphragm fittings, IUD insertion/removal, and contraceptive implant procedures are covered when performed according to state law and regulations. Medicaid recipients are exempt from co-payment requirements for family planning services.
Co-pay requirements apply to well-woman gynecological office services except for recipients under age 18.
Family planning services include evaluation and management visits, procedures, and supplies that prevent or delay pregnancy and are covered when provided according to state law. Nurse midwives are not authorized to perform sterilization procedures; other contraceptive services such as diaphragm fittings, IUD insertion/removal, and contraceptive implant procedures are covered when performed in accordance with applicable laws and regulations. Routine well-woman gynecological services (Pap screening, menopausal/hormonal treatments, STI treatment, and treatment of minor gynecologic illnesses) are reimbursable when provided by a nurse midwife.
Postpartum care is considered part of the delivery episode and includes routine visits within 60 days post delivery. Family planning services performed by the delivering provider on the day of the postpartum exam or within five (5) days of the postpartum exam are noncovered because they are included in the postpartum exam. If the midwife did not perform the delivery but provides postpartum care, family planning services rendered within five (5) days of the postpartum exam are likewise noncovered.
A provider may bill a Medicaid recipient for any noncovered service or for services provided to a recipient who has exhausted annual benefits. However, billing the recipient for services not paid by Medicaid due to provider-correctable claim submission errors or untimely filing is not permissible. Medicaid recipients are exempt from co-payment requirements for maternity care and family planning services; co-pay rules do apply to well-woman gynecological office services except for recipients under age 18.
Coding, CPTs, and Billing Windows
Provider Enrollment, Documentation & Billing Requirements
Antepartum-only coding requirement
Use the specified antepartum-only CPT procedure codes when billing Antepartum Care Only: CPT 59425 for four to six visits and CPT 59426 for seven or more visits; if fewer than four antepartum visits are provided, bill using office visit procedure codes. Antepartum-only claims do not count against the recipient's annual physician office visit limits.
Provider actions — none specified
No additional provider-specific actions are specified beyond those detailed elsewhere in the policy; providers should follow the enrollment, documentation, billing, and record requirements stated in this rule.
Required written records for midwife files
Maintain written evidence in the midwife's file that a delivery plan in a licensed hospital existed for each patient accepted for maternity/global care, keep a written statement naming the physician(s) with whom the midwife works and the signed working arrangement, and retain a complete medical record for each recipient.
- Written evidence that hospital delivery plans existed for each patient accepted for global care (filed in midwife's records).
- Written statement naming physician(s) and describing the working arrangement, signed by both parties with date.
- A complete medical record for each recipient.
Enrollment submission must include licensure and signed agreement
Submit a completed enrollment application with copies of current Registered Nurse and Certified Nurse Midwife licensure and the written signed agreement between the midwife and the physician consultant to the Alabama Medicaid Administrator of Nurse Midwife Program at the address provided.
- Completed enrollment application
- Copy of current RN licensure
- Copy of current CNM licensure
- Copy of the written, signed agreement between the nurse midwife and physician consultant
- Send documents to the Alabama Medicaid Agency (Administrator of Nurse Midwife Program, P.O. Box 5624, Montgomery, Alabama 36103-5624)
Participation and enrollment requirements
To participate the nurse midwife must complete enrollment, be approved, sign a contract, and be issued a provider number; only in-state and out-of-state providers within a 30-mile radius of Alabama's state line who meet requirements are eligible to participate.
- Complete enrollment application, be approved for enrollment, sign contract, and be issued a provider number.
- Out-of-state providers are eligible only if they practice within a 30-mile radius of Alabama's state line.
Hospital-employed midwife billing restriction and notification
Hospital-employed nurse midwives who are employed and paid by a hospital may not bill Medicaid for services performed for which the hospital is reimbursed; midwives with a Medicaid provider number must notify the Alabama Medicaid Agency of the name of any hospital(s) by which they are employed to prevent double payment.
- If employed and paid by a hospital, the midwife may not bill Medicaid for hospital-reimbursed services.
- Midwives with Medicaid provider numbers must inform the Alabama Medicaid Agency of hospital employer names regardless of regularity or frequency of employment.
Background and Scope
Nurse midwifery practice encompasses management of care for normal, healthy women and their newborns through the continuum of prenatal, intrapartum, postpartum, and well-woman gynecological services. Typical services include antepartum care and monitoring, management of labor and vaginal delivery (including routine professional hospital services related to delivery), routine postpartum visits, well-woman evaluations such as Pap screening and menopausal care, contraception counseling and procedures (except sterilization), treatment of common gynecologic problems and minor illnesses, and normal newborn care when applicable.
All nurse midwife services must be provided under appropriate physician supervision and within the scope authorized by state law. When accepting patients for maternity services, the midwife’s care plan must include arrangements for delivery to occur in a licensed hospital, and the midwife’s file should contain written evidence of those plans and a signed statement describing the working arrangement with the supervising physician. A complete medical record must be maintained for each recipient.
Definitions & Legal Authority
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