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Insurance Reimbursement

Pregnant Woman Enjoying her Drink

Currently, birth doulas and lactation support are covered through TRICARE Prime or TRICARE Select enrollees only for Tennessee. If you’re enrolled in TRICARE Prime, you’ll need a referral from your primary care physician or manager if you see a non-network provider. 

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To qualify for doula services, you must:

  • Be enrolled in TRICARE Prime or TRICARE Select

  • Be at least 20 weeks pregnant

  • See a TRICARE-authorized provider. 

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You can’t plan to give birth in a military hospital or clinic. Click here for more information.

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To qualify for lactation support, you must:

 

Although TRICARE is the only insurance covering doula and lactation support at this time, there are several types of third party payers who have reimbursed doulas for services on an occasional basis. 
 

The traditional indemnity plan (in which the consumer
chooses any practitioner and is reimbursed for a
percentage of covered expenses) seems more likely to
cover independent doula services than health maintenance organizations or preferred provider organizations under managed care. A few doulas have government contracts or grants from private foundations which cover the cost of providing services.

To date, Medicaid does not directly reimburse for doula
services in Tennessee, although Medicaid funds are allocated for doula
services by some county agencies. 

Many consumers have flexible spending accounts, in
which a percentage of their wages are placed in a pretax
account and can be used for non-covered medical
expenses. Doula care may be considered an appropriate
expense for reimbursement from a pretax account.

Below are some major healthcare providers who have provided coverage in the past:

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  • Aetna Healthcare

  • Travelers

  • Fortis Insurance

  • Qualchoice

  • Blue Cross/Blue Shield PPO

  • Cigna

  • Foundation for Medical Care

  • AltPro

  • Wausau Benefits, Inc.

  • Professional Benefits Administrators

  • Humana Employers Health

  • Glencare Managed Health Inc.

  • Lutheran General Physicians Org

  • Elmcare, LLC c/o No American Medical Management

  • Prudential Healthcare

  • Great West Life & Annuity Insurance Co.

  • United Healthcare

  • Mamsi

  • MDIPA

  • Alliance

  • Mail Handlers

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Steps Towards Reimbursement:

1. Pay your doula in full.
 

2. Get an invoice which includes the following information:
   

    a) The doula's name and address
    b) The doula’s NPI number (National Provider Identification)
    c) The doula’s social security number or taxpayer ID number
    d) The date and location services were provided
    e) The CPT (Current Procedural Terminology) code for the services provided
    f) A diagnosis code (which may need to be supplied by your doctor or midwife)
    g) The doula's signature

3. Submit the invoice with a claim form (provided by your insurance company, or the 1500
universal claim form if required) to your insurance company.

4. Within four (4) weeks, some times sooner, expect to receive a letter telling you either that:
   

    a) They have accepted the claim
    b) They need more information before they can process your claim
    c) This is not a covered expense

If the insurance company needs more information or denies your claim:

5. Ask your doula to send you the following:
   

    a) A copy of their certification (if they are certified)
    b) Other credentials or relevant training
    c) A letter detailing training and experience and how they served you

6. If possible, ask your doctor or midwife for a letter explaining how a doula helped you, was
necessary or saved the insurance company money. (Did you have a high-risk pregnancy or
postpartum? Did the birth doula's presence and/or suggestions appear to prevent
complications, help your labor to progress more quickly or decrease your need for expensive
pain medications? Did the postpartum doula’s presence and/or suggestions help you or your
baby in the postpartum period, increase breastfeeding success or appear to prevent
postpartum complications?)

7. Write a letter explaining why you felt the need for a doula and how you believe the doula was
beneficial to your and your baby’s health.

8. Submit to your insurance company:
   

    a) The doula's letter and credentials
    b) The letter from your doctor or midwife
    c) Your cover letter
 

9. If they refuse your claim, write a letter to your insurance company to the attention of Health
Services requesting that they review the claim, as you feel it was a cost-cutting measure and
they should cover the expense.

10. Follow up by telephone if necessary.

11. If the insurance company continues to deny your claim, write a letter to the company CEO
explaining why you feel that doula care should be a covered expense. They may not pay your
claim, but they may consider doing so for future claims.

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