Doula services prior authorization and coverage
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Defines medical necessity, coverage, limitations, and prior authorization requirements for certified doula services for Connecticut Medical Assistance Program (HUSKY Health) enrollees.
No material clinical or coverage changes in this revision.
Coverage Criteria for Doula Services
Criteria for additional doula visits
Additional four (4) antepartum or postpartum doula visits may be considered medically necessary when ALL of the following are documented by the CMAP‑enrolled physician or other licensed practitioner:
Source lists examples, not exhaustive.
Licensed practitioner must document purpose.
Authorization is based on medical necessity at time of review.
Services that fall outside the accepted scope of doula practice are not covered. Examples of services considered outside doula scope include: behavioral health services; healthcare/medical services related to pregnancy, birth, and the postpartum period; childbirth education groups; lactation consulting; nutritional counseling; postpartum binding after cesarean section; and transportation.
Doula services provided outside the specified timing windows are considered not medically necessary and are not covered. Specifically, antepartum/doula visits occurring more than nine (9) months prior to delivery and postpartum visits occurring more than twelve (12) months after delivery are not covered.
Billing Codes and Coding Guidance
| T1033 | Services performed by a doula birth worker, per diem |
Provider Actions, Prior Authorization, and Documentation
Obtain prior authorization for additional doula visits
Prior authorization is required for doula services beyond the included one labor/delivery attendance visit and four antepartum/postpartum visits; PA review is case-specific and based on medical necessity at time of review.
- PA is required only when requesting additional doula visits beyond the allowed four antepartum/postpartum visits.
- Authorization decisions are based on submitted case-specific information and medical necessity at time of authorization.
Exclude out-of-scope services from doula PA requests
Do not request or bill for services that are outside the scope of doula practice; these services are not covered as doula services and should be billed separately when appropriate.
- Examples not covered as doula services: behavioral health services; healthcare/medical services related to pregnancy, birth, and postpartum; childbirth education groups; lactation consulting; nutritional counseling; postpartum binding after cesarean section; transportation.
Include required forms and signed clinical note with PA
Submit a fully completed authorization request via fax, the Doula Services Prior Authorization Request Form, and include a signed and dated clinical note from the CMAP-enrolled physician or other licensed practitioner assuming responsibility for the pregnancy/postpartum.
- Clinical note must support medical necessity of additional doula services and clearly indicate the additional number of visits requested.
Document clinical justification and purpose for extra visits
Provide a signed and dated clinical note that documents the condition that may benefit from doula support and explains why additional visits are needed for the specified purposes in the policy.
- Clinical note must list the condition (examples include postpartum depression, anxiety, PTSD, substance use disorder, recent hospitalization, uncontrolled diabetes or hypertension, neonatal congenital conditions, feeding difficulties, hypercoagulation).
- Document the purpose for additional services (e.g., developing birth/postpartum plans; non-medical comfort measures; non-medical physical or emotional support; promoting self-care; providing resources for birth/breastfeeding/infant care; assisting communication with medical providers; connecting to community resources).
Avoid requests outside allowed timing to prevent denial
Requests for doula services provided more than nine months before delivery or more than twelve months after delivery are not covered and may be denied.
- Antepartum visits occurring greater than nine (9) months prior to delivery are not covered.
- Postpartum visits occurring greater than twelve (12) months after delivery are not covered.
Background
A doula is a trained, non-medical professional who provides physical, emotional, and informational support before, during, and after birth. Doulas offer non-medical comfort measures, help with birth and postpartum planning, assist with communication between the member and medical providers, and connect families to community resources to support positive maternal and newborn outcomes.
Definitions
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