Birth Doula Blog
If you are (or considering becoming) a Tricare Non-Network Doula and could use some guidance, you're in luck! I've created an excellent guide that can help you learn all about working with Tricare as a Non-Network doula. It's detailed, organized, and easy to read. It has helped multiple new and established doulas understand codes, and billing, and find answers to the most common questions.
Currently, doulas are left to guess or rely on others' advice to piece together what we should be doing to serve our military families. I recall being in literal tears trying to navigate coding, billing, and searching endlessly on the Humana website for answers. I took all of that knowledge and created this guide just for you!
It's the guide you wish Tricare had provided you with.
If you are interested, please make a $25 PayPal payment to @GuidingGatesDoula and you'll get access to the doc. Please include your email in the note. I also offer consults to answer your Tricare questions. Please book here.
Curious about doula coverage with Tricare? Read on to learn more and reach out if you have other questions!
Do I need a referral?
If you have Tricare Prime you will need a referral. Tricare Select does not need one.
How do I get a referral?
Find a Tricare approved doula and give her name, NPI, and contact info to your OB or midwife. I recommend you frequently check up on the status of your referral. If your provider is having a hard time creating one for you, speak to Patient Advocacy or contact your PCM.
How do I find a Tricare approved doula?
What's the difference between In-Network and Non-Network doulas?
The main difference for you is that an In-Network doula should not be asking you for payment upfront. They will work directly with Tricare to get paid. Most Non-Network doulas will require you to pay them directly and they will create a bill that you can later submit to Tricare for reimbursement. Non-Network doulas may also charge 15% more than the allowable Tricare amount.
How much does Tricare cover?
The amount is specific to location, but the average total is about $966.
Will there be any out of pocket costs?
A Non-Network doula is allowed to charge up to 15% more than the allowable amount. However, if the total cost of any doula's package is more than that, she might give you two bills: one for Tricare and another for the difference that Tricare does not cover and it might include additional services. Ask up front what your out of pocket costs will be after reimbursement.
How do doulas bill Tricare?
All In-Network doulas directly bill Tricare as do a few Non-Network. However, the majority of Non-Network doulas will provide you with a bill that will itemize your number of visits and your labor details. You will see the total you paid her broken up amongst those visits.
Does a doula have to provide me with the six allowable visits?
No, she will likely provide you with the same amount of visits she offers to her non-Tricare clients.
Are virtual prenatal visits covered?
Will I be reimbursed for virtual labor support?
No. Ask your doula what your financial responsibility is if labor support becomes virtual
What if a backup doula is used?
Only a Tricare approved backup doula is eligible for reimbursement. If a non-Tricare doula is used, you might have to pay out of pocket for her service. It is illegal for your original doula to bill Tricare for a labor she did not attend. Ask if your doula's backup is also Tricare approved.
If you are on Prime, you might have a tricky time getting reimbursed for that Tricare approved backup because your referral has been made to only one doula.
If you are on Select, both Tricare approved doulas should be covered as you do not have a referral with only one name tied to it.
Will I be reimbursed if labor ends in a C-section or loss?
Tricare will reimburse the cost of labor no matter the outcome as long as the doula provided any amount of in-person support.
What if I no longer need doula support or she fails to make it?
If you schedule a C-section and choose not to have a doula, if you fail to call your doula, or if she doesn't make it in time to provide in-person support, you may incur out of pocket costs or she could offer additional services in lieu of reimbursement. Make sure your contract details both of your financial responsibilties in the event of failure to provide services.
Will the demonstration cover postpartum doulas?
No. However, an approved labor doula may choose when to use her six allowable visits.
When can I set up visits with a doula?
You may hire a doula at any point during your pregnancy but Tricare will not cover sessions before 20 weeks.
How do I submit a bill for reimbursement?
Most Non-Network doulas will provide you with a super bill that will include codes and fees. You will need to mail this along with DD Form 2642 to the appropriate address. You have one year from date of service to submit your claim. If your claim is denied, reach out to your doula ASAP so she can make any corrections. Most claims are processed by Tricare within 30 days (but could take up to 90) and a check will be mailed to you. You can check the status of your claim by logging into your Tricare portal or giving them a call.
On January 1, 2022, Tricare debuted their Childbirth and Breastfeeding Support Demonstration which will run until December 31, 2026. This demonstration seeks to study the impact birth doulas and lactation counselors/consultants have on the services of cost, quality of care, and maternal and fetal outcomes for the Tricare population.
In order to get reimbursed for doula services, you must:
•Be at least 20 weeks pregnant upon your first prenatal visit
•Be enrolled in Tricare Prime or Tricare Select
•If you have Tricare Prime, obtain a referral from your PCM to see a provider for the management of your pregnancy AND for doula services
•Choose prenatal care with a Tricare-authorized OB/GYN or a Certified Nurse Midwife (CNM)
•Choose in-person labor support. Prenatal and postpartum visits may be in-person or virtual
•Use Tricare as your primary insurance