Fee Schedule for Doulas
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Statewide fee schedule governing reimbursement rates, billing units, and billing rules for enrolled doulas providing prenatal, labor/delivery, postpartum, newborn-visit attendance, and miscarriage/abortion support services to Illinois Department of Healthcare and Family Services recipients.
No material clinical or coverage changes in this revision.
Coverage criteria for doula services
Coverage criteria for doula services
Reimbursement is allowed for specified doula services when all of the following coverage, timing, unit limit, and billing rules are met.
ALL of the following
ALL of the following
- Appearance of a code on the fee schedule does not guarantee payment; services for which medical necessity is not clearly established are not covered by the Department's Medical Programs.
- NCCI procedure-to-procedure and medically unlikely edits apply.
ALL of the following
Postpartum visit attendance (one of):
- Attendance reimbursable when the doula accompanies the birthing person to a practitioner postpartum visit occurring within 0–26 days from delivery; delivery date must be reported on the claim in Loop 2300 DTP*454 of the 837P.
- Attendance reimbursable when the doula accompanies the birthing person to a practitioner postpartum visit occurring between 27–89 days from delivery; delivery date must be reported on the claim in Loop 2300 DTP*454 of the 837P.
- Maximum of 2 postpartum visit attendance payments (one per time period). If multiple claims for a single time period are received, the first payable claim received will be reimbursed.
- Initial newborn visit attendance (CPT 99381) reimbursable when the doula accompanies the birthing person to the initial newborn visit occurring within the first two weeks following delivery; CPT 99381 must be billed under the newborn's recipient ID and may be billed for each child of a multiple birth.
ALL of the following
- Telehealth delivery modality is allowed only when the service is of an amount and nature sufficient to meet the key components of a face-to-face encounter.
ALL of the following
- S9445 (Non-physician Prenatal Patient Education) - billable in 15-minute increments per unit; individual unit price $15.00; HQ modifier for group (2+ individuals) reduces unit price to $5.00; maximum 8 units/day; statewide daily maximum amount reimbursable $120.00 for individual and $40.00 for group (HQ).
- T1032 (Doula support during or after miscarriage or abortion) - billable in 15-minute increments; unit price $15.00 per 15-minute increment; maximum 8 units/day; statewide daily maximum amount reimbursable $120.00.
- 59409 (Labor & Delivery Support - Vaginal Delivery only) - one payment per pregnancy; statewide payment $720.00; daily unit max quantity = 1; payable once per pregnancy.
ALL of the following
- All fees listed are statewide rates and do not vary by population group or geographic region.
Codes, rates, and quantity limits
| S9445 | Non-physician Prenatal Patient Education - billable in 15 min increments; individual unit price $15.00; HQ modifier for group (2+) reduces unit price to $5.00; max 8 units/day; daily max $120.00 (individual) / $40.00 (group) |
| T1032 | Doula support during or after miscarriage or abortion - billable in 15 min increments; unit price $15.00; max 8 units/day; daily max $120.00 |
| 59409 | Labor & Delivery Support - Vaginal Delivery Only; one payment per pregnancy; statewide payment $720.00 |
| 99381 | Initial Newborn Visit - facilitation & attendance (must be billed under newborn recipient ID); reimbursable if visit occurs within first two weeks |
Provider responsibilities and billing guidance
Medical necessity and payment disclaimer — denial risk
Please note the appearance of a code on this fee schedule does not guarantee payment. Services for which medical necessity is not clearly established are not covered in the Department's Medical Programs; consult Chapter 100, Topic 104 and Chapter A-200, Section 204 for additional exclusions. NCCI procedure-to-procedure and medically unlikely edits also apply.
- Failure to demonstrate medical necessity may result in claim denial.
- Do not assume listing of a CPT code guarantees reimbursement.
Telehealth allowance — permitted if equivalent to face-to-face
Telehealth delivery is permitted when the service provided is of an amount and nature sufficient to meet the key components of a face-to-face encounter.
- Ensure telehealth encounters include the same key components as an in-person visit to qualify for reimbursement.
Key definitions and term clarifications
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