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    v1.0.28
    OpenPayerPolicy UpdatesObstetrics/Gynecologyhusky_health certified doula services Coverage | O…
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    Currenthusky_healthPolicy N/A

    Certified doula services — coverage criteria (HUSKY Health)

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    Defines coverage, billing, referral, and prior authorization requirements for certified doula services for HUSKY Health members (Connecticut Medicaid) effective January 1, 2025, and explains limits by HUSKY plan type.

    Policy Summary
    Payerhusky_health
    PolicyCertified doula services — coverage criteria (HUSKY Health)
    Policy CodePolicy N/A
    Change TypeNew benefit additionPA requirement added
    Effective DateJan 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization for doula services if more than four antepartum or postpartum visits are requested.
    SourceLink
    POLICY UPDATE CHANGES

    Certified doula services are covered for HUSKY A, B, and C members effective January 1, 2025 with specified visit limits and billing codes.

    Prior authorization is required for doula services beyond the initial four antepartum/postpartum visits.

    1attendance visit (labor)
    4ante/post visits covered
    50%max telehealth proportion

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    T1033
    primary HCPCS code
    T1033-HDattendance modifier/code

    Coverage Criteria for Certified Doula Services

    Standard coverage

    Covered when ALL of the following are met:

    Enrollment and referral: Doula is independently enrolled in CMAP (or doula group) and services are recommended/referred/ordered by a licensed and CMAP-enrolled physician, APRN, PA, or CNM.

    FQHCs cannot bill an encounter rate for doula services; the doula must bill directly or the doula office must be enrolled separately.

    Service types and limits: One in-person visit associated with attendance at labor and delivery plus a total of four antepartum or postpartum perinatal visits.1 attendance visit; 4 ante/post visits

    Antepartum visits may occur up to nine months prior to delivery and postpartum visits through 12 months after delivery. No more than half of the allotted antepartum or postpartum visits may be performed via telehealth. Prior authorization is required for doula services beyond the initial four antepartum or postpartum visits.

    Plan applicability: Covered for HUSKY A, HUSKY B, and HUSKY C members; HUSKY D: not applicable.

    Out-of-network services are not covered and claims from providers not enrolled in CMAP will not be reimbursed.

    Coding and billing constraints: Services must be billed using HCPCS code T1033 for perinatal visits and T1033-HD for in-person attendance at birth.

    Clinic visit/encounter code (e.g., T1015) cannot be reported in combination with doula procedure codes; hospitals cannot bill directly for doula services rendered in the outpatient hospital—doula must bill directly.

    Out-of-country care is not a covered benefit except for specified U.S. territories (for example, Puerto Rico and certain U.S. territories where emergency care may be covered). Out-of-network services are not covered; providers must be enrolled in CMAP to be reimbursed. Non-emergent out-of-state or out-of-country care follows these exclusions. (See DSS PB 2025-14 for additional details on benefit limitations and coverage criteria.)

    Billing constraints related to network status: the doula procedure codes cannot be reported together with HCPCS code T1015 (clinic visit/encounter, all inclusive). Federally Qualified Health Centers (FQHCs) may establish a separate office and enroll in CMAP as a doula/doula group to provide doula services and must bill as that enrolled entity; claims submitted by an FQHC must include the certified doula as the rendering provider.

    Services that are not medically necessary, cosmetic, unproven/experimental, or provided for research purposes are excluded from coverage. Additionally, services for which prior authorization is required but not obtained may be denied. General exclusions also include services that are beyond what is necessary to treat the member’s medical problem or unrelated to the illness/problem at the time of treatment.

    Other routine exclusions apply such as services that are social, habilitative, vocational, recreational, or educational in nature, services required by third parties (for example, school or employer requirements), and services or items for which the provider does not usually charge.

    Billing, Codes, and Telehealth Rules

    Covered HCPCS CodesHCPCSCovered
    T1033Services performed by a doula/birth worker, per diem
    T1033-HDServices performed by a doula/birth worker, per diem - specific to attendance at birth (modifier/code listed)
    Billing constraints / Not to be combinedHCPCSNot Covered
    T1015Clinic visit/encounter, all inclusive (cannot be reported with doula procedure codes)
    inv-06: Telehealth proportion — maximum allowed telehealth share of ante/postpartum visits
    Maximum telehealth shareNo more than half (50%) of the allotted antepartum or postpartum visits may be performed via telehealth.
    Applicable visit typesApplies to the total of four antepartum or postpartum perinatal visits allowed per pregnancy (antepartum up to 9 months prior; postpartum through 12 months after delivery).
    Plan applicabilityApplies to HUSKY A, HUSKY B, and HUSKY C members where the doula benefit is effective January 1, 2025.
    ConsequenceVisits exceeding the telehealth proportion must be in-person to meet coverage limits; PA required only for visits beyond the total allowed visits, not for telehealth specifically.

    Provider Requirements, Prior Authorization, and Claim Submission

    Prior Authorization

    Prior authorization required for additional doula visits

    Prior authorization is required when requesting doula services beyond the covered allotment of four antepartum or postpartum visits.

    Step Therapy

    Step therapy / sequencing

    No specific step‑therapy or sequential treatment requirement is specified in this policy.

    Documentation Required

    Referral and claim rendering requirements

    Doula services must be recommended/referred/ordered by a licensed and CMAP‑enrolled physician, APRN, PA, or CNM; Federally Qualified Health Centers (FQHCs) submitting claims must include the certified doula as the rendering provider.

    Definitions

    inv-13: Perinatal visit — HCPCS T1033 per diem for antepartum/postpartum visits
    Primary HCPCS codeT1033 — Services performed by a doula/birth worker, per diem (used for perinatal antepartum/postpartum visits).
    Perinatal visit definitionT1033 is the per diem code to report doula-provided antepartum or postpartum visits.
    Billing classDoula services are considered a professional service; doulas must be enrolled with CMAP/HUSKY Health and bill directly.
    inv-14: Attendance at birth — in-person attendance at labor/delivery reported with T1033-HD modifier/code
    Attendance-at-birth codeT1033‑HD — HCPCS code/modifier specific to in-person attendance at labor and delivery.
    Coverage detailOne visit associated with in-person attendance at labor and delivery is covered per delivery for HUSKY A, B, and C members effective January 1, 2025.

    Background

    Doula services provide non-clinical perinatal support during the antepartum, intrapartum, and postpartum periods. The HUSKY benefit covers one in-person attendance at labor and delivery plus up to four antepartum or postpartum visits per pregnancy. Antepartum visits may begin up to nine months prior to delivery and postpartum visits are covered through 12 months after delivery.

    Only up to 50% of the allotted antepartum or postpartum visits may be performed via telehealth. Doula services must be provided by a certified doula who is independently enrolled in CMAP (or a doula group enrolled in CMAP) and must be recommended/referred/ordered by a licensed and CMAP-enrolled physician, APRN, PA, or CNM. Prior authorization is required for doula services beyond the initial four antepartum or postpartum visits.

    Quick Metrics & Key Codes

    Policy Summary
    Payerhusky_health
    PolicyCertified doula services — coverage criteria (HUSKY Health)
    Policy CodePolicy N/A
    Change TypeNew benefit additionPA requirement added
    Effective DateJan 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization for doula services if more than four antepartum or postpartum visits are requested.
    SourceLink
    On This Page
    Coverage Criteria for Certified Doula ServicesBilling, Codes, and Telehealth RulesProvider Requirements, Prior Authorization, and Claim SubmissionDefinitionsBackgroundQuick Metrics & Key Codes
    • Referrals/orders must come from a licensed, CMAP‑enrolled physician, APRN, PA, or CNM.
    • When an FQHC bills for doula services, the claim must list the certified doula as the rendering provider or the FQHC must enroll a separate doula office in CMAP.
    Note

    CMAP enrollment and out‑of‑network reimbursement

    Providers must be enrolled in CMAP to be reimbursed; out‑of‑network services are not covered and non‑emergent out‑of‑state care is subject to coverage restrictions.

    • FQHCs may establish a separate office and enroll in CMAP as a doula/doula group to bill for doula services.
    • Out‑of‑network services are not covered for HUSKY A, B, and C; HUSKY D is not covered.
    Denial Risk

    Common reasons claims will be denied

    Claims are likely to be denied for services that lack required prior authorization, are not medically necessary, or are considered unproven/experimental, and for services or providers not enrolled in CMAP.

    • Services requiring PA but provided without authorization may be denied.
    • Services that are not medically necessary, cosmetic, or experimental/unproven may be denied.
    • Claims from providers not enrolled in CMAP will not be reimbursed.
    Billing requirementThe doula must be independently enrolled in CMAP and bill the attendance-at-birth service using T1033‑HD; hospitals cannot bill for doula services rendered in outpatient hospital settings.