CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Obstetrical Services — Reimbursement and Billing Rules

Governs reimbursement and billing rules for prenatal, labor/delivery and postpartum obstetrical services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines for participating providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyObstetrical Services — Reimbursement and Billing Rules

Policy CodePolicy N/A

Change TypeNon‑material coding and benefit additions

Effective DateN/A

Next Review DateDec 11, 2024

Key ActionVerify member eligibility, coverage and prior authorization requirements before providing services.

SourceLink

POLICY UPDATE CHANGES

Added patient education classes benefit language/HCPCs and newborn claim submission requirements.

Added Doula services effective 7/1/22 for Medicaid and Commercial Plans.

up to 3routine standard ultrasounds reimbursed per pregnancy

48 / 96 hrsearly discharge home visit eligibility (vaginal/cesarean)

30 daysnewborn claims under mother's ID

59400,59510,59610,59618CPT codes in global OB package

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Coverage and Billing Criteria

Coverage and billing criteria

What Neighborhood will reimburse and how services should be billed.

Global maternity billing: Providers should file global maternity care when they provide prenatal care, labor/delivery and postpartum care; the global OB package includes services per CPT (examples: 59400, 59510, 59610, 59618) and encompasses initial and subsequent history, physical exam, weight, blood pressure, fetal heart tone monitoring, routine urinalysis, routine prenatal visits, management of uncomplicated labor and delivery including admission, and postpartum hospital/office visits.

Confirmation of pregnancy

The confirmation of pregnancy visit is typically minimal; if the OB record is started the same day this visit is included in the global package and is not separately reimbursable.
If pregnancy has already been confirmed by another clinician (e.g., ultrasound or blood test), do not bill a separate confirmation of pregnancy visit.

When prenatal, delivery or postpartum may be billed separately

Member coverage starts after onset of pregnancy.
Coverage terminates prior to delivery.
Pregnancy does not result in delivery.
Another provider in a different practice assumes care prior to completion of global services.
There is a change in the member's benefit package during the pregnancy.

Single and multiple birth billing rules

Single birth
- Vaginal delivery only: file the appropriate vaginal delivery only code.
- Cesarean delivery only: file the appropriate cesarean delivery only code.
- Global delivery: file the appropriate global vaginal or global cesarean delivery code.
Multiple births: Vaginal deliveries: Baby A — file global vaginal or vaginal-only code; Babies B and beyond — file vaginal delivery only code with modifier 51 appended; claims reimbursed per multiple procedure payment policy.
Cesarean multiple births: For cesarean deliveries, file only once for the appropriate global cesarean delivery code or cesarean-only code (with modifier -22 appended where indicated).

Ultrasound reimbursement

Routine obstetric ultrasounds: Neighborhood will reimburse up to three (3) routine standard ultrasounds during each pregnancy.
Additional limited or follow-up ultrasounds are reimbursed only when a diagnosis or condition is suspected that represents an abnormality of pregnancy or a threat to the fetus or delivery; such follow-up scans should be billed to the appropriate ultrasound codes and supported by clinical documentation and indication.

Patient education and separable services

Neighborhood covers childbirth preparation, cesarean birth, lactation and parenting classes; these patient education classes are covered and listed as separate service codes.
Services unrelated to pregnancy but performed by the provider rendering global maternity care must be documented and reported separately with the appropriate inpatient or outpatient E&M code using a non-pregnancy primary diagnosis; these services are separately reimbursed outside the global obstetrical package.

Exclusions and investigational items

3D/4D ultrasounds are investigational and not medically necessary (not covered).
Doula services are not covered for INTEGRITY; pre-planned home births or services provided by a doula during a home birth, water births, routine ultrasounds to determine fetal gender without medical concern, and ultrasound 'pictures' of the fetus are not covered.

Newborn claim submission: Newborn claims may be submitted under the mother's member ID for the first 30 days following birth; thereafter claims must be submitted under the newborn's member ID.

Documentation and medical necessity: Neighborhood may request medical records for any billed service; documentation must support billed services and medical necessity and claims are subject to coding, documentation and audit procedures.

coverage stance

The document lists codes relevant to maternity, delivery, ultrasound, newborn visits, and patient education services and states that listing is not a guarantee of coverage.

Inclusion of a CPT/HCPCS code in this policy does not guarantee coverage or reimbursement; claims will be adjudicated based on member benefit coverage, eligibility, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and state and federal regulations.

Representative obstetric and ultrasound codes (examples)

59400, 59425, 59426, 59430, 59510, 59610 (routine obstetric care and related antepartum/postpartum codes).
Ultrasound codes: 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817.
Patient education and related codes: S9436, S9438, S9443, S9444, S9445; newborn/home-visit codes: 99501, 99502, T1001, T1002.

Relevant CPT/HCPCS and Coding Notes

Representative obstetric and ultrasound CPT codesCPTCovered

59400	Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care
59425	Antepartum care only; 4-6 visits
59426	Antepartum care only; 7 or more visits
59430	Postpartum care only (separate procedure)
59510	Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
59610	Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery
76801	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation

obstetric, ultrasound, newborn, and patient education codesmixed

59400	Routine obstetric care including antepartum care, vaginal 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
59412	External cephalic version, with or without tocolysis
59414	Delivery of placenta (separate procedure)
59425	Antepartum care only; 4-6 visits
59426	Antepartum care only; 7 or more visits
59430	Postpartum care only (separate procedure)
59510	Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
59514	Cesarean delivery only

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1/5

Routine standard ultrasounds per pregnancy

Maximum routine standard ultrasounds per pregnancyUp to 3 routine standard ultrasounds per pregnancy

Code inclusion note

Inclusion caveatInclusion of a code in this policy does not guarantee coverage or reimbursement; claims are adjudicated based on member benefits and eligibility

Claims subject to editsClaims are subject to claims payment edit rules, coding and documentation guidelines, and authorization policies

Contract and regulatory limitsPayment is also subject to provider contract agreements and state and federal regulations

Provider Verification, Authorization, and Claims

Prior Authorization

Prior Verification and Prior Authorization

It is the provider's responsibility to verify member eligibility, benefit coverage, and any prior authorization or precertification requirements before rendering services. Neighborhood may use NCDs, LCDs, InterQual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies when determining medical necessity.

Refer to Neighborhood's Plan-specific Prior Authorization Reference page for authorization requirements and submission instructions.
Contact Provider Services at 1-800-963-1001 with questions about eligibility, coverage, or prior authorization.

Denial Risk

Authorization and Claims Adjudication

Claims are subject to payment only when services are medically necessary and covered under the member's benefit plan. Payment is contingent on member eligibility at the time of service and compliance with claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract terms, and applicable state and federal regulations. This policy is informational and is not a guarantee of payment; all billed services remain subject to audit.

Definitions and Scope Notes

Doula

DefinitionA doula is a person trained to provide advice, information, emotional support, and physical comfort to a mother before, during, and just after childbirth

Coverage (where applicable)Prenatal, labor and delivery, and postpartum doula services are covered for Medicaid and Commercial plans (except INTEGRITY as noted elsewhere)

Effective / history noteDoula services were added to the policy (see Document History for implementation dates); coverage specifics vary by line of business and contract

Global OB package

Global OB componentsInitial and subsequent history; physical examination; recording of weight; blood pressure checks; monitoring of fetal heart tones; routine chemical urinalysis; routine prenatal visits; management of uncomplicated labor and delivery including admission; postpartum hospital and office visits following vaginal and cesarean delivery