Insurance Billing for the Homebirth Midwife
Guest post by: Nicholas Marine
While cost shouldn’t be the first factor that pregnant women consider when it comes to who delivers their baby, for many women it can be the only factor that matters. Accepting insurance is one way to help offset some of the prohibitive costs that newly expectant parents have to deal with. By reducing the financial burden on your patients, you will be able to attract and retain more business while still receiving the same amount of payment for the services that you are providing to your patients.
For three years, I operated a medical insurance billing company submitting claims for many midwives around the nation. Today, I will teach you the basics of how to submit a claim to an insurance company on your own.
***NOTE: Please keep in mind that I wrote this document in March of 2018, so depending on when you read this, things may have changed.
First, there are a few important terms to learn so that you know exactly what is being discussed. In order to submit a claim to an insurance company, you will have to fill out what is called a CMS-1500 form. A CMS-1500 is a form that has been agreed upon to be the standard for professional medical services. The CMS-1500 is specifically for professional claims only; there is a second form used by facilities (Hospitals, Birth Centers, etc.) called a UB-04 or CMS-1450, which will not be used to bill for homebirth midwife services. The CMS-1500 consists of around 33 different fields, which we will go over together.
The next term to learn is clearinghouse. A clearinghouse is a company that facilitates the submission of a claim. When you go to submit an insurance claim, you do not typically submit the claim directly to the insurance company; it is instead sent to the clearinghouse, which acts as an intermediary between the healthcare provider and the insurance company. The clearinghouse that we used most often was OfficeAlly. I highly recommend creating an account with them and using their services, as they are almost free to use, have excellent customer service support and an easy to use interface. I believe that in three years of doing business with them, the most expensive monthly invoice that I received from them was for less than $6.
Claims are created primarily by entering two types of codes into the CMS-1500 form: these are diagnosis codes (ICD-10) and procedure codes (CPT codes). The most up-to-date version of the diagnosis codes are called the ICD-10 codes and these were released on October 1st of 2016--they should be used for at least the next ten years. However, every year, some changes can be made to these codes, so you shouldn’t assume that your codes are always correct. Procedure codes are split into two types: CPT codes and HCPCS codes. These codes can also be adjusted every year but are typically fairly stable. The most common codes that you will use are the CPT codes, however, some state Medicaids (such as Florida Medicaid) do require prenatal procedures to be billed with HCPCS codes.
Creating a CMS-1500 with Office Ally:
You will first need to create an account with Office Ally (www.OfficeAlly.com) to submit insurance claims. After creating your account with them, you will log into your account. Once you log in to the account, you will come to the Service Center home page. On the left-hand side of the website is the Available Services. Hover your mouse over “Online Claim Entry” and select “Create Professional (CMS-1500) Claim”. This will take you directly to a blank CMS-1500.
On the top right corner of the form, you will see the Payer Name section. You will need to select the “OA Payers” button, which will make a popup menu of all insurance companies that Office Ally works with. The way that a clearinghouse sends a claim to a specific insurance company is through something called a Payer ID number. For example, Florida Blue is listed as BCBS Florida and the payer ID number is 00590, Aetna is listed as Aetna and their payer ID number is 60054, etc.. You may need to do some creative searching to find the correct ID number. You can also get this number when you call the insurance company to verify benefits
How to fill out the CMS-1500
Each field on the CMS-1500 has an associated number, 1 – 33b. I will go line by line explaining how to fill out the form.
1. Select the appropriate type of insurance company. For regular insurance, typically select “Group Health Plan”, for a Medicaid policy select “Medicaid”, and for a Health Sharing Plan (like Christian Care Ministries) select “Other”.
1A. INSURED’S ID NUMBER: Enter to patient’s policy number. For a BCBS policy, include the alphanumeric prefix.
2. PATIENT’S NAME: Enter the last name and then first name of your patient.
3. PATIENT’S BIRTHDATE: Enter the date of birth of your patient and select the appropriate sex.
NEXT MOVE TO BOX 5 NOT BOX 4
5. PATIENT’S ADDRESS: Enter the address, city, state, and phone number for the patient.
6. PATIENT RELATIONSHIP TO INSURED: Select the appropriate option. Read the insurance card--if it only lists one person, then that person should be the policyholder. If the card lists the entire family, then the person’s name that is highest on the list would be the policyholder. For Medicaid policies, always select “self”.
4. INSURED’S NAME: Enter the first and last name of the policyholder. You can use the “Copy from Patient” option if you selected “self” in box 6. The policyholder could be the patient, the newborn, the partner, or the parent of the patient depending upon what type of policy they have.
7. INSURED’S ADDRESS: Put the policyholder’s information into this section, address, city, state, phone, etc.
8. LEAVE BLANK
9. LEAVE BLANK
10. PATIENT’S CONDITION RELATED TO: Select “No” for all options.
11. INSURED’S POLICY GROUP OR FECA NUMBER: On the insurance card, it should list a “Group Number”, enter it into this field. If the insurance card does not include the group number, you may need to call the provider services number on the back of the card and speak with the Benefits department for that information.
11A. INSURED’S DATE OF BIRTH: This is the policyholder’s, not the patient’s, date of birth and sex.
11B. LEAVE BLANK
11C. LEAVE BLANK
11D. LEAVE BLANK, UNLESS SUBMITTING A SECONDARY CLAIM
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE: Select Yes.
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE: Selecting “Yes” in box 13 will signify to the insurance company that you have received authorization from the patient to receive the insurance payment directly. If you select “No”, then the payment would be sent to the patient. However, some insurance companies have policies that specify where the payment will be sent regardless. Box 13 is called the “Assignment of Benefits”.
14. DATE OF CURRENT ILLNESS, INJURY, OR PREGNANCY (LMP): If the claim is for a patient, then enter the LMP and enter “484” into the “QUAL.” Section. If the claim is for a newborn, then leave all of 14 blank.
15. LEAVE BLANK
16. LEAVE BLANK
17. LEAVE BLANK
17A. LEAVE BLANK
17B. LEAVE BLANK
18. LEAVE BLANK
19. LEAVE BLANK
20. OUTSIDE LAB? Select “No”.
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY: This is the section where you enter all of the diagnosis codes for the patient using ICD-10 codes. Click here for a reference sheet that has most of the common ICD-10 codes that you would ever need to use. I will go into greater detail in the next section on how to select the appropriate code. When using the CMS-1500, select the appropriate code and enter it into the first empty field (A, B, C, D… etc.). If you did not end up using a specific diagnosis code in the procedure section of the claim, do not enter it in this section (if a diagnosis code is entered in this section but not used in the procedure section, the claim may be rejected). Also, make sure that the “ICD ind” box in the top right corner of box 21 is selected to ICD-10, this should be the default selection.
22. RESUBMISSION CODE: For a new claim, you will leave this blank. However, if you are submitting a corrected claim (each insurance company can have different policies on how to submit a corrected claim, check with them first), then the most common way to do it is to resubmit the claim the exact same way that you submitted it the first time, however you enter a “7” into box 22. The Original Reference Number would be the original claim number, again, this is only used for corrected claims.
23. PRIOR AUTHORIZATION NUMBER: If you have received a prior authorization, a gap exception, or anything of that nature, enter the authorization number into this section. If you do not have an authorization (they are not always required), then leave this blank.
24. This is the primary purpose of the entire CMS-1500 form. Box 24 is where everything comes together. Each row (1, 2, 3 … etc.) indicates one service that you have rendered for your patient. This allows you to submit one CMS-1500 with multiple services at the same time. Each of the following bullets in this section will refer to each column of box 24.
a. DATE OF SERVICE: Enter the date of service for the procedure you are submitting a claim for. If you are submitting a claim with the global maternity code (which includes services rendered prenatally, during labor and birth, and postpartum), then you would only enter the date of service for the date of delivery. If you are submitting for the global prenatal code, then you would enter the date of the first routine prenatal visit and the last prenatal visit. Other services that only occur on one day, simply enter the same date of service for both from and to.
b. PLACE OF SERVICE: For services rendered in the patient’s home, enter 12. Services rendered in the office, enter 11. Services rendered in a birth center would be 25.
c. EMG: Leave Blank
d. CPT/HCPCS: This is where you enter the procedure code. I will provide a list of the most common CPT codes in the next section.
MODIFIER (A, B, C, D): You can potentially enter up to 4 modifiers on a procedure. In most cases, you can leave this blank. However, if you have had to bill two visits on the same day for whatever reason, then you could potentially use modifier code “25”. A google search for CPT Modifier list will bring up as much information as you need for them. Avoid using them unless necessary.
e. DIAGNOSIS POINTER: This is the section where you indicate what the diagnosis was for the procedure that was performed. You enter the alpha character from box 21 (A, B, C … etc.) not the actual diagnosis code.
f. CHARGES: Enter the specific amount that you charged for the service that you are billing for. In most cases, if you are submitting a global claim, you would use your global fee. However, there will be times where you must submit an itemized claim. In that situation, you will have to have separate fees for each service you are performing. A good basis for determining your fees for individual services is to look up a Medicaid fee schedule and increase it by 150-300%.
g. DAYS OR UNITS: For most services, you will select “1”. However, for some services you must indicate the number of units used--this could be for indicating time in a labor management that ends in a transfer or for billing time spent in a birth pool.
h. EPSDT FAMILY PLAN: LEAVE BLANK
i. ID QUAL: This can vary depending upon what the insurance company requires. In most cases, you will select “ZZ”.
j. RENDERING PROVIDER #: What you enter into the top box will depend upon what you entered into section “i”. If you selected the “ZZ” option, then you would need to enter your taxonomy code. If you do not know your taxonomy code, then you can go to the “NPPES NPI Registry” website, search for your NPI number, and it will provide your taxonomy code. For most midwives, the code is 176B00000X. However, some insurance companies will have their own individual code that they want you to enter into this section.
The bottom half of section j is where you enter your NPI number.
25. FEDERAL TAX I.D. NUMBER: If you are operating as a LLC or a corporation, then you would want to enter your Tax ID Number (TIN) or your Employer Identification Number (EIN). The TIN and the EIN are the same thing as far as we are concerned. However, if you practice directly under your own name and do not use a business name, then you can submit a claim directly under you Social Security number. You do not need to include the hyphens. Select the appropriate option for SSN or EIN.
26. PATIENT’S ACCOUNT NUMBER: This can be left blank or you can enter some code for your own organization; it is not used by the insurance company.
27. ACCEPT ASSIGNMENT? In most cases, select “No”. By selecting yes, you are agreeing to accept the allowed amount (what the insurance company pays for any given procedure—usually much less than your actual fee) as the maximum amount that you can collect from your patients. If you select “No”, then you can still balance bill your patients. If the claim is a Medicaid claim or if you are contracted with the insurance company, select “Yes”.
28. TOTAL CHARGE: This is the total of the charges that you have entered into the boxes in 24 and is totaled automatically.
29. AMOUNT PAID: If you selected “Yes” in box 13, then you can leave this section blank. However, if you selected “No”, then you have to enter the amount that the patient has paid you at this point.
30. LEAVE BLANK
31. LEAVE BLANK (This section in the bottom left corner can be left blank)
32. SERVICE FACILITY LOCATION AND INFORMATION: This section would only be used if services were rendered in a Birth Center. For home or office services, leave blank.
33. BILLING PROVIDER INFO. & PHONE #:
a. For the billing provider, enter the name of your practice if you are operating as a LLC/Corp. or enter your name if you are billing directly under your social security number. If you do bill under your name, include your credentials, for example, Jane Smith LM.
b. Enter the address information where your practice is based.
c. If you are practicing under a business name, you will need to create a “Type 2” NPI. This type 2 NPI will have its own taxonomy code associated with it--enter that into “Billing Provider Specialty/Taxonomy”. If you do not have a Type 2 NPI because you are practicing directly under your name, then enter your usual taxonomy code.
d. Rendering provider is the name of the healthcare provider that actually performed the procedures (typically it is you). If there are multiple midwives, then you would have to submit separate claims for each individual service they performed; be careful not to bill the same procedure under multiple providers.
e. Under Rendering Provider Specialty/Taxonomy enter the same Taxonomy code you used in section 24j.
f. The provider PIN # will automatically populate from the information in box 24.
33A. BILLING/GROUP NPI: If you practice under a LLC, enter the TYPE 2 NPI. If you practice under your name, enter your TYPE 1 NPI.
33B. BILLING/GROUP NO: This is similar to box 24J. If you are practicing under an LLC/Corporation, then enter the Taxonomy Code that is tied to the practice Type 2 NPI. If you are practicing directly under your name, then select the Taxonomy code for your Type 1 NPI.
After completing this final section, review the entire CMS-1500 to make sure that there were no errors on the claim. An error at this point can cause over a month in payment delays once it is submitted. Once you have verified that the information is correct, press the update button (CAUTION! THE CANCEL BUTTON WILL DELETE YOUR ENTIRE CLAIM). On the next screen you can view a copy of the CMS-1500. I strongly recommend that you save a PDF copy of the CMS-1500 so that you have all of the necessary information when you call the insurance company to check the status of the claim.
Knowing what ICD-10 Code to select can be a difficult task. The insurance companies require that you be as specific as possible. Fortunately, with Office Ally, you can look at every ICD-10 code when you are submitting a claim. If you hover your mouse over the small box in section 21 that has “…” in it, and then select “ICD-10 System Defined List”, you can search through the entire list of ICD-10 codes to find the appropriate version. You will need to enter some information because there are many thousands of codes to look through. Additionally, we are giving you a reference sheet with this paperwork that includes all of the common codes you will use. While the insurance companies want you to be as specific as possible, this is one situation where less is more. For most prenatal visits, you can get away with using Z34.90, which is a routine pregnancy, unspecified number of pregnancies, unspecified trimester. Normally, you would have three different options for which trimester the patient is in and then another two options for whether or not your patient is a primip or a multip. For a global pregnancy code, (CPT Code 59400), you would use O80 and Z37.0. For postpartum care, you would use Z39.2. The most common newborn codes are Z00.110, Z00.111, and Z38.1.
Note: When entering ICD-10 codes into box 21 of the CMS-1500, do not include the period (use Z00110 instead of Z00.110). This is only for Office Ally; different clearinghouses may have different requirements.
For the most part, knowing which CPT code to use can be pretty straightforward. However, with pregnancy, there can be some difficulty knowing which code is appropriate. In the vast majority of cases, you are going to submit a claim with one code for the entire pregnancy, CPT Code 59400. This code includes all prenatal care, postpartum care, and the delivery. In order to be eligible to use this code, you must have performed a minimum of 4 prenatal visits, the delivery, and 2 postpartum visits. When you use 59400, the date of service for the claim is the date of the delivery.
If you are in a situation where the patient transfers into your care and the previous provider submits a claim for prenatal care, then you are no longer eligible to use the global pregnancy code. Instead you will have to submit an itemized claim. For your initial prenatal visit, you would typically bill a 99204, follow up prenatal visits would be bundled under either 59425 (which is for 4 – 6 prenatal visits) or under 59426 (which is for 7 or more prenatal visits). The global pregnancy and the global prenatal codes are only billed with one unit. You would also be able to submit claims for any urinalysis (81000) or blood draws (36415). The delivery would be billed as a 59410 (which is the delivery and the immediate postpartum) and the remaining postpartum visits would be billed as 59430. You could also bill a 6 week postpartum visit with 99404 (along with ICD-10 code Z30.02).
In order to submit a claim for labor management that does not result in a delivery, you will have to use several codes. First you submit for the initial home visit with 99350 (ICD-10 O75.9 – unspecified complication of labor and delivery). On the next line on the CMS-1500, use CPT code 99354, which is for an additional hour beyond your normal visit, then bill 99355 for each additional half hour. For example, if you had a 12-hour labor management, you would bill 99350 for the initial set up and management, one hour under 99354, and then the remaining 11 hours under 99355 (remember 99355 is for each half hour, so you would use 22 units to get to 11 hours).
The different types of NPIs:
There are two types of NPIs, Type 1 NPI and Type 2 NPI. The type 1 NPI is your individual NPI that tied directly to you and is used for any claims that you submit. You may not necessarily have a Type 2 NPI. A Type 2 NPI is also called your group NPI. A group NPI must be created and is tied directly to your practice, so if you work as HomeBirth Midwife LLC, you would get a Type 2 NPI for HomeBirth Midwife LLC and then that business also have its own TIN/EIN. I highly recommend that you create your business in this manner so that the payments from the insurance company are made directly to your practice and not to you. That way you can still have LLC protections in the event that you need them. Speak with an accountant for information on how to set up an LLC and the protections that they can afford you.
Before you can accept insurance as a form of payment from your patient, you first need to know what kind of insurance they have. To do this, you will need to get a copy of the patient’s insurance card. From the card, you need to collect the membership ID number, the group number (if available), and the provider services phone number on the back of the card.
Call the phone number on the back of the card and work through the automated system to get to a live representative. You will need to know the patients first and last name, date of birth, and membership ID number. Make sure to get the representative’s name and a reference number. Ask them for the in and out-of-network deductible, copayments, coinsurance, out-of-pocket maximum. Additionally, and most importantly, you need to ask specifically if this policy covers out-of-hospital or homebirth services. In most cases, the representative will not know anything about this and it can take some time for them to do additional research. Once they come back with an answer for you, make sure to verify if your provider type is eligible for coverage, as some policies may specifically exclude Licensed Midwives but may offer coverage to Certified Nurse Midwives.
Right now, you are probably thinking, “But Florida/insert your state Law requires insurance policies to cover Licensed Midwives.” That is correct, however, Federal Law (specifically ERISA) states that “Self-Funded” insurance policies do not have to follow state laws. Because of this, many insurance policies can exclude LMs. Only “Fully-Funded” policies have to follow state law. As part of the verification of benefits process, it is important to obtain this information as well.
In addition to the patient’s benefits, it is important to find out whether or not prior authorization is required by the policy. Most representatives will immediately state that yes, prior authorization is required, however, you need to ask if that is only for the “48/72 hour rule” (this means that authorization is required if the mother is in the hospital for more than 48 hours after a vaginal delivery or 72 hours following a cesarean delivery). If that is the case, then authorization is not necessarily required for the home birth.
In addition to asking about authorization, ask if it is possible to request a “Gap Exception” (if they do not recognize that term ask about “obtaining an authorization for an out-of-network provider to get in-network benefits due to the fact that there are no in-network providers in the area that offer the services the patient is looking for”). If the policy does allow a Gap Exception, then you need to ask whether or not you retain the right to “balance bill” the patient. If the insurance company says that you can balance bill the patient, be sure to get a reference number confirming this. However, if they state that you can not balance bill the patient, then that would mean that if you submit the gap exception request, then you are agreeing to accept the amount that the insurance company allows as payment in full. If you have collected anything above the allowed amount, then you would legally have to refund it to the patient. In some cases, you will be able to negotiate a discounted amount with the insurance company, called a “Letter of Agreement” (LOA). If you do agree to accept the LOA, then you must follow the agreement.
If you can submit a gap exception request or you do need to obtain an authorization, you will follow the exact same procedure. You will be transferred to the authorization department and will most likely submit the authorization request to the representative. You will need to submit medical records via fax. When they ask a reason for the request, repeat that you are requesting a geographical gap exception based on the fact that to your knowledge, there are no in-network healthcare providers that can offer home birth maternity services.
List of CPT and ICD-10 Codes to request for an authorization:
59400 (Global OB) ICD-10: 080, Z37.0; x 1 unit
59425 (Routine Prenatal Appointment) ICD-10: Z34.90; x 6 units
59426 (Routine Prenatal Appointment) ICD-10: Z34.90; x 20 units
59430 (Routine Postpartum Appointment) ICD-10: Z39.1; x 4 units
59409 (Normal Spontaneous Vaginal Delivery) ICD-10: O80, Z37.0; x 1 unit
59410 (Normal Spontaneous Vaginal Delivery including Immediate Postpartum) ICD-10: O80, Z37.0; x 1 unit
99461 (Newborn Exam) ICD-10: Z00.110; x 1 unit
99350 (Home visit for the evaluation and management of an established patient; Labor Management without Delivery) ICD-10 O75.9; x 5 units
99354 (Prolonged Services in the office or outpatient setting requiring direct contact beyond usual service, 1st hour; Labor Management without Delivery) ICD-10: O75.9; x 1 unit
99355 (Prolonged Services in the office or outpatient setting requiring direct contact beyond usual service, each additional 30 minutes; Labor Management without Delivery) ICD-10: O75.9; x 40 units
PROCEDURE/SERVICE CPT Code
Pregnancy Confirmation Visit 99204
Urine Pregnancy Test 81025
Initial Prenatal Exam 99205
Routine Prenatal Exam 1-3 Visits 99213
Routine Prenatal Exam 4-6 visits 59425
Routine Prenatal Exam 7+ visits 59426
Problem Prenatal Exam 99214 (25 mins)
Problem Visit 99214
37-wk Home Visit 99350
Urinalysis Dipstick 81000
Finger Stick HGB/HCT 36416
Blood Glucose (in office) 36416
Pap Smear Q0091
Specimen Handling 99000
28-wk Rhogam Inj. (Procedure) 99506, 96372
Rhogam (Med) J2790
Non-Stress Test 59025
Global OB/Maternity 59400
Vaginal Delivery Only 59409
Global OB/Maternity (VBAC) 59610
Vaginal Delivery Only (VBAC) 59612
Vaginal Delivery Only 59410
Delivery of Placenta 59414
(separate from delivery)
Labor Management Only 99350
Labor Management 1st Hour 99354
Labor Management 99355
(each additional 30 mins)
Homebirth Supplies 99070, S8415
Hydrotherapy 97113, 97036, 97022 (tub)
(billed in increments of 15 mins)
Routine Postpartum Visit 59430
6-wk Postpartum 99404
Family Planning/Counseling Visit
Newborn Care/Exam 99461
Birth Assistant 99464
(Billed on Infant Claim)
Neonatal Resuscitation 99465
General Postpartum 99502
(Home, 24 hrs – 2 wks)
General Postpartum 99502
Newborn Visit/Exam (Office)
6-wk Postpartum 99391, 99214
Vitamin K Injection J3430
Erythromycin Ointment 99070
Newborn Metabolic Screening S3620
Complete Blood Count (CBC) 85025
ABO Blood Typing 86900
+RH Testing 86901
Hepatitis B 87340
Rubella Antibodies 86762
Hemoglobin A1c 83036
Vitamin D 82306
Urine Culture 87086
Antibody Screen 86850
RPR Syphilis 86592
GBS Screening 87081