CurrentAnthemPolicy G-14001

Maternity Services Reimbursement Policy

Defines Anthem New York Medicaid reimbursement rules for global obstetrical services (antepartum, delivery, postpartum), what is included/excluded in the global package, billing expectations, and claim denial/recoupment conditions; applies to providers billing Anthem Blue Cross and Blue Shield HP for New York Medicaid members.

Policy Summary

PayerAnthem

PolicyMaternity Services Reimbursement Policy

Policy CodePolicy G-14001

Change TypeNo material change

Effective Date07/07/2023

Next Review DateN/A

Key ActionAnthem may request medical documentation and reserves the right to require authorization/medical necessity and post-pay review of paid claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

279pregnancy period days allowed for global code

13typical prenatal visits included

6postpartum visits included (weeks)

NYapplicable state

Coverage Criteria for Maternity Services

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Maternity Services

Reimbursement rules and denial conditions for global and component maternity services

Allow one global obstetrical code per pregnancy (defined as 279 days) when billed by a single provider or provider group reporting under the same federal Tax Identification Number (TIN).

Reimbursement for a global obstetrical code is based on the provider or provider group (same TIN) providing all antepartum, delivery, and postpartum services; if not all components are provided, bill only the elements actually provided.

Anthem will not reimburse for duplicate or overlapping services during the course of the pregnancy; claims may be denied or previously paid overlapping claims may be recouped.

Service-level denial/recoupment conditions

If global, delivery only, delivery/postpartum, antepartum only, or postpartum only services have been paid for the same pregnancy, a claim for global services may be denied or may cause recoupment of overlapping services.
If global, delivery only, or delivery/postpartum services have been paid for the same pregnancy, a claim for delivery only services may be denied; delivery-only services are reimbursed separately to assistant surgeons only for cesarean deliveries when the appropriate modifier is appended.
If global, delivery only, delivery/postpartum, or postpartum only services have been paid during the same pregnancy, a claim for delivery/postpartum services may be denied or may cause recoupment.
If global or antepartum only services have been paid during the same pregnancy, a claim for antepartum only services may be denied.
Postpartum-only claims may be denied if global, delivery/postpartum, or postpartum only services have already been paid during the same pregnancy.

Providers must use appropriate diagnosis codes indicating outcome of delivery and weeks of gestation on professional delivery service claims; failure to include required diagnosis coding may result in denial.

Included and Separately Billable Services

Items included in the global package and items allowed to be billed separately

Included in the global obstetrical package (not separately reimbursable when any CPT code for global services is billed)

Initial and subsequent history and physical exams when pregnancy diagnosis has already been established.
All routine prenatal visits until delivery (typically monthly through 28 weeks, then biweekly until 36 weeks and weekly until delivery) — usually 13 visits.
Additional visits for a high-risk pregnancy for potential or inactive problems (when antepartum activities are part of the global package).
Collection of weight, blood pressure, and fetal heart tones.
Routine urinalysis.
Admission to the hospital including history and physical.
Inpatient E/M services that occur within 24 hours of delivery.
Management of uncomplicated labor (including administration of labor-inducing agents).
Insertion of cervical dilators on the same date as delivery.
Simple removal of cerclage.
Vaginal (including forceps or vacuum assisted) or cesarean delivery of single gestation and delivery of the placenta.
Repair of first- or second-degree lacerations.
Uncomplicated inpatient visits following delivery.
Routine outpatient E/M services within six weeks of delivery.
Discussion of contraception; postpartum care only; education on breastfeeding, lactation, exercise, or nutrition.

Not included in the global package (may be billed separately)

Initial E/M visit to diagnose pregnancy when antepartum activities are not initiated.
Laboratory testing (excluding routine urinalysis).
Additional antepartum E/M visits (in excess of 13) for a high-risk complication that is active in the current pregnancy — these additional visits must be submitted for payment only at the time of delivery with Modifier 25 and an appropriate high-risk diagnosis.
Additional E/M visits for conditions unrelated to pregnancy — may be reported as they occur if clearly unrelated to pregnancy.
Maternal or fetal echocardiography procedures; amniocentesis; chorionic villus sampling; fetal contraction stress testing and nonstress testing; biophysical profile; amnioinfusion.

Coding and Visit Counts

Delivery outcome and gestational age codingICD-10

Providers must use appropriate diagnosis codes indicating outcome of delivery and gestational weeks on professional delivery service claims.

Routine prenatal visits included

Routine prenatal visits includedTypically 13 routine prenatal visits are included in the global obstetrical package (monthly through 28w, biweekly until 36w, then weekly until delivery)

Additional high‑risk antepartum E/M visitsAdditional antepartum E/M visits in excess of 13 for an active high‑risk complication may be billed separately but must be submitted at time of delivery with Modifier 25 and an appropriate high‑risk diagnosis

Routine postpartum E/M servicesRoutine outpatient E/M services within 6 weeks of delivery are included in the global package and are not separately reimbursable

Routine components includedCollection of weight, blood pressure, fetal heart tones, and routine urinalysis are included in the global package and not separately reimbursable

Documentation, Billing Restrictions, and Provider Responsibilities

Documentation Required

Documentation and Review — Anthem may request medical documentation and reserves the right to require authorization/medical necessity and post-pay review of paid claims

Anthem may request medical documentation to support services and reserves the right to require authorization, medical necessity review, and post-pay review of paid claims. Providers should use appropriate E/M codes for antepartum and postpartum care and ensure documentation fully supports billed services.

Anthem may request medical records for pre‑ or post‑payment review.
Providers must ensure documentation supports use of E/M codes for antepartum/postpartum care.

Billing Rule

Global Code Billing Restriction — global obstetrical codes allowed once per pregnancy (279 days) when billed by a single provider or provider group under same TIN; duplicate billing conditions noted

Global obstetrical codes are allowed only once per pregnancy (defined as 279 days) when billed by a single provider or provider group reporting under the same federal Tax Identification Number (TIN). Reimbursement assumes the provider/TIN furnished all elements of the global obstetric package (antepartum, delivery, and postpartum). If the provider or provider group did not provide all elements, global codes must not be used; submit only the specific elements provided. Anthem will not reimburse duplicate or overlapping services and may deny claims or recoup previously paid overlapping/global services.

Global obstetrical codes allowed once per pregnancy (279 days) when billed by a single provider or provider group under the same TIN.
If all antepartum, delivery, and postpartum services were not provided by the billing provider/TIN, do not bill global codes — bill only the elements actually provided.
Anthem will not reimburse duplicate or overlapping services; claims for globals may be denied or prior payments recouped if overlapping services were paid.

Definitions and Documentation Requirements

Claims Requiring Additional Documentation

Distinct procedural services modifiersClaims flagged as distinct procedural services using Modifiers 59, XE, XP, XS, or XU are considered Claims Requiring Additional Documentation

Maternity ultrasound guidanceMaternity outpatient ultrasound claims are identified as Claims Requiring Additional Documentation and should follow the separate outpatient ultrasound policy (CG‑Med‑42)

Modifier 25 and 57 usageModifier 25 (and where applicable Modifier 57) are referenced in definitions as triggers for additional documentation when billing separate E/M services related to pregnancy care

Documentation submissionAdditional antepartum E/M visits for active high‑risk complications must be submitted at time of delivery with Modifier 25 and an appropriate high‑risk diagnosis to support separate payment