CurrentHighmark Blue Cross Blue Shield WnyPolicy G-14001

Maternity Services, Reimbursement Policy

Governs reimbursement rules for global obstetrical and related maternity services for Highmark BCBS members in specified New York Medicaid programs (MMC, HARP, CHPlus, Essential Plan). Affects providers billing obstetric services to Highmark BCBS in those programs.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyMaternity Services, Reimbursement Policy

Policy CodePolicy G-14001

Change TypeNo material change

Effective Date07/07/2023

Next Review DateN/A

Key ActionUse appropriate diagnosis codes and support billed services with medical record documentation; Highmark may request records for post-pay review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

279pregnancy period (days)

13typical prenatal visits included

07/07/2023effective date

MMC/HARP/CHPlus/Essentialapplicable programs

Maternity Coverage Criteria

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.

Reimbursement for global obstetrical codes is allowed once per pregnancy period (defined as 279 days) when billed by a single provider or provider group reporting under the same federal TIN; duplicate or overlapping services will not be reimbursed.

The global obstetrical package encompasses antepartum, delivery, and postpartum care; reimbursement assumes the provider or provider group reporting under the same TIN provides all elements of the global package. If all elements are not provided by that provider/group, global codes may not be used and only the services actually provided should be billed.

Included in global package

Initial and subsequent history and physical exams when pregnancy diagnosis has already been established
All routine prenatal visits until delivery (typically 13 visits: monthly through 28 weeks, biweekly until 36 weeks, then weekly until delivery)
Additional visits for a high-risk pregnancy or potential problems that do not develop or are inactive in the current pregnancy
Collection of weight, blood pressure, and fetal heart tones
Routine urinalysis
Hospital admission 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 of delivery
Simple removal of cerclage
Vaginal (including forceps or vacuum-assisted) or cesarean delivery of single gestation
Delivery of 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

Services that may be billed separately from the global package

Initial E/M visit to diagnose pregnancy when antepartum record 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 are payable only at the time of delivery and must be submitted with Modifier 25 and an appropriate high‑risk diagnosis
Submit additional high-risk antepartum visits at time of delivery with Modifier 25 and high‑risk diagnosis
Additional E/M visits for conditions unrelated to pregnancy (reportable as they occur and must clearly be unrelated to pregnancy)
Maternal or fetal echocardiography procedures

If global, delivery-only, delivery/postpartum, antepartum-only, or postpartum-only services have been paid for the same pregnancy, subsequent overlapping claims may be denied and prior payments may be recouped.

Providers must report appropriate diagnosis codes on professional delivery service claims to indicate delivery outcome and gestational weeks; failure to report required diagnosis codes will result in claim denial.

All billed CPT/HCPCS/revenue codes must be supported by the medical record. Highmark BCBS reserves the right to request medical documentation and perform post-pay review of paid claims.

Billing, Modifiers, and Included Services

Modifiers and coding guidanceModifier

Modifiers 25, 59, XE, XP, XS, XU

Modifiers referenced for distinct procedural services and maternity-related claims

Included routine prenatal visits

Routine prenatal visits includedAll routine prenatal visits until delivery (typically 13 visits: monthly through 28 weeks, then biweekly until 36 weeks and weekly until delivery)

Routine monitoring elementsCollection of weight, blood pressure, and fetal heart tones are included

Routine testing includedRoutine urinalysis is included and not separately reimbursable

Inpatient and immediate post-delivery careInpatient E/M services within 24 hours of delivery, management of uncomplicated labor, delivery of placenta, and repair of first- or second-degree lacerations are included

Postpartum and educationRoutine outpatient E/M services within six weeks of delivery, discussion of contraception, and breastfeeding/lactation education are included

Reporting additional antepartum E/M visits

Additional antepartum E/M for active high-risk complicationsAdditional antepartum E/M visits in excess of 13 for a high-risk complication active in the current pregnancy are payable only when submitted at time of delivery with Modifier 25 and an appropriate high-risk diagnosis

Initial E/M to diagnose pregnancyInitial E/M visit to diagnose pregnancy may be billed separately when antepartum record activities are not initiated

Nonpregnancy-related E/M visitsAdditional E/M visits for conditions unrelated to pregnancy may be reported as they occur if clearly not related to pregnancy

Other separable servicesProcedures such as amniocentesis, chorionic villus sampling, fetal testing, maternal-fetal medicine care, and ultrasound are not included and may be billed separately

Authorization, Documentation, and Billing Actions

Documentation Required

Documentation and authorization — keep complete records and meet medical necessity

Highmark BCBS reserves the right to request medical documentation for post‑pay review of paid claims; all billed CPT/HCPCS/revenue codes must be fully supported in the medical record and services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.

Use industry‑standard, compliant CPT/HCPCS/revenue codes on all claim submissions.
Maintain medical records/office notes that fully support the services billed; Highmark may request these for post‑pay review.
Ensure services meet authorization and medical necessity guidelines for the procedure, diagnosis, and member's state of residence.

Denial Risk

Prior authorization / duplicate service risk — one global code per pregnancy period

Global obstetrical codes are allowed only once per pregnancy period (defined as 279 days) when billed by a single provider or provider group reporting under the same federal TIN; duplicate or overlapping global/delivery/postpartum claims may be denied or prior payments recouped.

Reimbursement is based on the provider/group under the same TIN furnishing all aspects of the global package (antepartum, delivery, postpartum); if not all components were provided, submit only the elements actually provided.
If global, delivery‑only, delivery/postpartum, antepartum‑only, or postpartum‑only services have been paid for the same pregnancy, subsequent overlapping claims may be denied or cause recoupment of previously paid claims.

Key Definitions and Modifier Meanings

Claims Requiring Additional Documentation (Modifiers 59, XE, XP, XS, XU)

DefinitionClaims Requiring Additional Documentation = Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)

PurposeThese modifiers identify services that may be considered distinct procedural services requiring additional documentation

Policy linkageSee general reimbursement definitions for requirements when submitting claims with these modifiers

Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service (Modifier 25)

Modifier 25 definitionSignificant, separately identifiable E/M service by the same physician on the same day of the procedure or other service

Use with additional antepartum visitsModifier 25 must be appended to additional antepartum E/M visits (in excess of 13) for active high-risk complications when submitted at time of delivery

Documentation requirementServices reported with Modifier 25 must be clearly distinct from routine pregnancy care and supported by the medical record