CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

doula_services_billing_and_coverage_policy

Policy governs coverage and billing requirements for doula services for Blue Cross Blue Shield Rhode Island (BCBSRI) Commercial products only, including permitted visits per pregnancy, required CPT/HCPCS code, modifiers, place of service, telemedicine provisions, credentialing requirement for in-network doulas, and reimbursement coordination when multiple doulas attend labor/delivery.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policydoula_services_billing_and_coverage_policy

Policy CodePolicy N/A

Change Typeclarified

Effective DateJan 1, 2022

Next Review Date

Key ActionDoulas must submit a formal credentialing application and must be certified by the Rhode Island Certification Board (RICB) to be credentialed as in-network providers.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 10/18/2023 per header; published in Provider Updates November 2023 and December 2021.

6Allowed prenatal/postnatal visits

1Allowed labor and delivery encounters

0Member cost share

Policy overview

Background: A doula is a paraprofessional who provides emotional and physical support, advice, guidance, and companionship to pregnant persons, birth parents, partners, and families before, during, and after pregnancy. The policy explicitly notes postpartum support is available up to 12 months and may include non-medical supports, newborn care help, and bereavement support when needed.

Covered services and limits: Per pregnancy, members are allowed up to 6 prenatal/postnatal visits (combined) and 1 labor and delivery encounter. A doula visit is defined as a visit of at least 60 minutes. Only the doula who provided services at the initiation of labor and delivery should file the claim and will be reimbursed; that doula is expected to coordinate reimbursement portioning with other doulas who attended.

Covered services and coverage rules

Covered Doula Services per Pregnancy

Doula services are covered for Commercial members as follows per each pregnancy:

ALL of the following

Prenatal visits and postnatal visits up to the first 12 months postpartum
Members allowed up to 6 visits for prenatal and postnatal services
Labor and delivery services: 1 encounter unit of billing
One labor and delivery encounter is covered regardless of duration or how the pregnancy ends
If more than one doula provides services for labor and delivery, only the doula who provided services at initiation of labor and delivery should file the claim and will be reimbursed
Initial doula expected to coordinate reimbursement portioning with other doulas
There is no member cost share for doula services (no deductible, coinsurance, or copayment) for BCBSRI Commercial members
Self-funded employer groups may elect to include/exclude doula services

Service Duration and Unit Billing

ALL of the following

A doula visit is considered a visit of at least 60 minutes>= 60 minutes
Providers shall bill one (1) unit of service for each visit in which doula services are provided; should not submit claims for services less than 60 minutes
Members are allowed up to 6 visits for prenatal and postnatal services and one labor and delivery encounterup to 6 visits per pregnancy; 1 labor & delivery encounter

Provider enrollment, credentialing, and billing actions

Provider Enrollment and Credentialing

Doulas must submit a formal credentialing application to render in-network services to BCBSRI members

Doula must be certified by the Rhode Island Certification Board (RICB) to be credentialed

Documentation Required

In‑network credentialing required

Doulas must submit a formal credentialing application and must be certified by the Rhode Island Certification Board (RICB) to be credentialed as in‑network providers.

Billing Rule

Use HCPCS S9445 and bill one unit per >=60-minute visit

Participating perinatal doula providers must bill HCPCS S9445. Providers shall bill one (1) unit of service for each visit in which doula services are provided; do not submit claims for services less than 60 minutes.

S9445

Billing Rule

Labor & delivery billing and coordination

If more than one doula provides services for labor and delivery, only the doula who provided services at the initiation of labor and delivery should file the claim and will be reimbursed; that initial doula is expected to coordinate reimbursement with other doulas who provided portions of the delivery.

Only the doula who initiated labor files the claim and is reimbursed; coordinate reimbursement with other doulas

Codes, modifiers, place of service, and telemedicine rules

Covered CPT/HCPCS for doula servicesHCPCSCovered

S9445

Patient education, not otherwise classified, non-physician provider, individual, per session

Required ModifiersModifier

FP	Service provided as part of family planning program (used for prenatal services per policy)
XU	Unusual non-overlapping service (use for attendance at delivery)
TH	Obstetrical treatment/services, prenatal or postpartum (use for postnatal services)
95	Synchronous telemedicine service via real-time interactive audio and video (use as secondary modifier for audio-visual telemedicine)

Place of Service codes guidance (examples)mixed

02	Telehealth - Patient not located in their home
10	Telehealth - Patient located in their home
12	Home
11	Office
22	Outpatient Hospital (example facility code listed in text)

Telemedicine and Place of Service

ALL of the following

POS options
- Place of Service (POS) 02: The location where health services and health related services are provided or received through telecommunication technology: patient is not located in their home when receiving services via telecommunication technology
- Place of Service (POS) 10: The location where health services and health related services are provided or received through telecommunication technology: patient is located in their home when receiving services via telecommunication technology
All other services should use an appropriate place of service code (e.g., 12 - Home; 11 - Office; 22 - [facility])
Document lists examples; provider must choose appropriate POS

Claims Submission and Modifier Requirements

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Denial Risk

Modifier use required to identify doula services

Claims must be submitted with modifiers to identify doula service type: FP for prenatal, XU for attendance at delivery, TH for postnatal. Use modifier 95 as the secondary modifier for audio‑visual telemedicine. Failure to use the required modifiers may result in the claim not reimbursing under the doula benefit.

Billing Rule

Place of service requirements for telemedicine

Prenatal and postnatal telemedicine visits must be billed with POS 02 when the patient is not located in their home and POS 10 when the patient is located in their home. All other services should use an appropriate place of service code (examples listed).

Document changes

10/18/2023policy_updateLatest

Policy last updated 10/18/2023; update treated as informational with no substantive clinical coverage changes (non-material).

November 2023publication_note

Published in Provider Update, November 2023; informational publication of the policy.

December 2021publication_note

Published in Provider Update, December 2021; informational publication of the policy.

Provider FAQs and common questions

Surface operational FAQs if available in source: common questions to include are credentialing steps for RICB-certified doulas, billing when multiple doulas attend a delivery, required billing code and modifiers, telemedicine place-of-service rules, and how to bill for visits under 60 minutes.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

Policydoula_services_billing_and_coverage_policy

Policy CodePolicy N/A

Change Typeclarified

Effective DateJan 1, 2022

Next Review Date

Key ActionDoulas must submit a formal credentialing application and must be certified by the Rhode Island Certification Board (RICB) to be credentialed as in-network providers.

SourceLink

On This Page

OpenPayer

doula_services_billing_and_coverage_policy

Policy overview

Covered services and coverage rules

Provider enrollment, credentialing, and billing actions

Codes, modifiers, place of service, and telemedicine rules

Key definitions

Document changes

Provider FAQs and common questions