CurrentCentenePolicy CP MP.136

Home Births

Policy governing coverage and medical necessity criteria for planned home birth services for members/enrollees of Centene-affiliated health plans, including required provider qualifications, patient selection, and emergency arrangements.

Policy Summary

PayerCentene

PolicyHome Births

Policy CodePolicy CP MP.136

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDocument a written emergency care plan showing emergency transport to the nearest appropriate hospital can be accomplished within 15 minutes and ensure two planned caregivers attend with one NRP-certified for the infant.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 minrequired maximum emergency transport time to hospital

2minimum planned attendants at delivery

37–41wksgestational age window for eligibility

singletonpregnancy type required

NRPrequired infant-care certification

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Medically necessary when ALL of the following are met

Covered when ALL of the following are met:

Provider qualifications: Birth is overseen by a participating and credentialed provider who meets required qualifications; if managed by a midwife, the midwife is AMCB-certified (or meets ICM global standards for midwifery education and licensure) and practices within an integrated and regulated health system; if managed by a physician, the physician practices obstetrics within an integrated and regulated health system and, if not an obstetrician or a family physician who completed an obstetrics fellowship, there is documented back-up supervision/coverage by a board-certified or active candidate for certification OB/GYN; supervising obstetrician must have admitting privileges at the planned emergency facility.

Emergency planning: A written emergency care plan documents that emergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes from onset of an emergency condition and there is a preexisting arrangement for emergency transportation to a nearby hospital.

Attendant and resuscitation: Two care providers are planned to be present at the birth: one with primary responsibility for the birthing individual and one with primary responsibility for the infant who is certified in the Neonatal Resuscitation Program and has equipment to perform full neonatal resuscitation.

Patient selection criteria: No preexisting medical condition(s) that increase pregnancy risk; singleton pregnancy estimated appropriate for gestational age; fetal presentation is cephalic; no prior cesarean delivery; absence of significant antepartum or intrapartum disease.

Gestational age criteria: Either spontaneous labor at 37 0/7 weeks through 41 6/7 weeks OR outpatient induction at 39 0/7 weeks through 41 6/7 weeks.

The following conditions exclude coverage for planned home birth: prior cesarean delivery, multiple gestation, non‑cephalic fetal presentation, significant antepartum or intrapartum disease, or other preexisting medical conditions that increase pregnancy risk. These exclusions reflect the policy's patient selection requirements that aim to limit planned home birth to low‑risk, singleton pregnancies appropriate for gestational age.

Home birth is not supported when the policy's required provider qualifications, emergency transport planning, or patient selection criteria are not met. Examples that would render a planned home birth unsupported include absence of credentialed participating providers practicing within an integrated and regulated health system, lack of a written emergency transport arrangement to a nearby hospital, failure to plan for two caregivers at delivery (including an NRP‑trained infant caregiver), or when patient factors listed under exclusions are present.

Billing, Documentation, and Provider Responsibilities

Billing Rule

Billing / prior authorization guidance for delivery CPT codes

Claims for routine obstetric delivery and related CPT codes (e.g., 59400, 59409, 59410, 59414) should follow usual professional coding guidance; inclusion of these CPT codes does not guarantee coverage and providers must reference up-to-date coding guidance when submitting claims.

Step Therapy

Step therapy

No step therapy requirements are specified in this policy for planned home birth services.

Documentation Required

Required documentation for planned home birth

Document and retain written evidence of required provider qualifications, an emergency care plan with transfer time, admitting privileges, and planned attendants.

Written emergency care plan documenting that emergency transportation to the nearest appropriate hospital can be accomplished within 15 minutes from onset of an emergency condition.
Proof of provider certification/licensure (AMCB certification or ICM-equivalent midwifery education/licensure, or physician obstetrics qualifications and documented backup supervision/coverage if applicable).
Documentation that the supervising obstetrician has admitting privileges at the planned emergency facility.
Documentation that two care providers will attend the birth, including one provider with primary responsibility for the infant who is certified in the Neonatal Resuscitation Program and equipped for full neonatal resuscitation.

Denial Risk

Triggers for denial / not medically appropriate

Home birth claims may be denied when required provider, patient-selection, or emergency-planning criteria are not met.

Lack of required provider qualifications or licensing/credentialing.
No written emergency transport plan or transport time to hospital exceeds 15 minutes.
Supervising obstetrician lacks admitting privileges at the planned emergency facility.
Fewer than two planned caregivers or absence of an NRP-certified caregiver with resuscitation equipment.
Presence of exclusions such as prior cesarean delivery, multiple gestation, non‑cephalic presentation, significant antepartum/intrapartum disease, or gestational age outside specified windows.

Background and Evidence Context

Planned home birth is described in this policy as an elective alternative to hospital or birthing‑center delivery and is reserved for low‑risk pregnancies supported by an integrated system of care. The evidence base is mixed: observational data show fewer maternal interventions with planned home birth but have also reported an increased risk of neonatal death compared with planned hospital birth. For these reasons the policy emphasizes strict patient selection, specified gestational age windows (spontaneous labor at 37 0/7–41 6/7 weeks or outpatient induction at 39 0/7–41 6/7 weeks), required provider qualifications within an integrated and regulated health system, planned attendance by two caregivers with one NRP‑certified provider, and a written plan for emergency transport to a nearby hospital.

Key Definitions

Planned home birth definition

DefinitionAn elective delivery at home managed by a credentialed provider with a written plan for emergency transport and integrated referral/transfer arrangements.

SettingDelivery occurs in the birthing individual's home as an alternative to hospital or birthing center delivery.

Decision frameworkBirthing individuals are encouraged to make medically informed decisions; coverage considered when mandated by law or member benefit language.

Required systemsPlanned home birth must include a system for collaboration, referral, and timely transfer to hospital care if problems arise.

Risk screeningAppropriate risk screening is required to evaluate eligibility and safety for out-of-hospital birth.

NRP-certified provider definition

DefinitionA care provider certified in the Neonatal Resuscitation Program (NRP) with the equipment and training to perform full neonatal resuscitation in accordance with NRP principles.

Role at birthPlanned home births must include two care providers: one responsible for the birthing individual and one responsible for the infant who is NRP-certified.

EquipmentMust have equipment to perform full resuscitation of the infant per Neonatal Resuscitation Program standards.

Training expectationProvider should have appropriate training and skills to optimize potential resuscitation and immediate neonatal care in the home setting.

OpenPayer

Home Births

Medical Necessity — Planned Home Birth

Referenced Procedure Codes

Billing, Documentation, and Provider Responsibilities

Background and Evidence Context

Key Definitions

59400	Routine obstetric care including antepartum care, delivery (with or without episiotomy and/or forceps) and postpartum care
59409	Vaginal delivery only with or without episiotomy and/or forceps
59410	Vaginal delivery only with or without episiotomy and/or forceps; including postpartum care
59414	Delivery of placenta, separate procedure