NEW YORK STATE MEDICAID PROGRAM

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New York State Doula Manual Policy Guidelines

V.20

March 1, 2019

Table of Contents

SECTION I – Provider Enrollment
Doula Participation Requirements
NYS Medicaid Doula Enrollment Process

SECTION II – Doula Services
Scope of Services
Doula Services by Stage of Pregnancy
Limitations in the Role of the Doula
Member Eligibility for Doula Services

SECTION III – Billing
Billing Guidance
Language Interpretation Services
eMedNY
ePACES Claim Submission
Paper Claim Submission
Confidentiality
Record–Keeping Requirements

SECTION IV – RESOURCES

Doula Guidance – Important Links

Medicaid Updates

Periodically, updates to the Doula policy guidelines will be made and posted on the NYS Medicaid program´s Medicaid Update website. Medicaid updates are published monthly.

Provider Communications

Periodically, communications are posted on the Doula Manual website.

Doula Fee–For–Service Fee Schedule

For information regarding billing a Medicaid Managed Care (MMC) plan, please contact the MMC plan directly. General contact information for each MMC plan is in Section IV of the manual.

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Section I – Provider Enrollment

Doula Participation Requirements

To participate in the New York State (NYS) Medicaid doula pilot program, a doula must enroll as a NYS Medicaid provider. To be eligible for enrollment, a doula must complete and submit an attestation form confirming that the doula has received training in all of the following core competencies:

  • At least 24 contact hours of education that includes any combination of childbirth education, birth doula training, antepartum doula training, and postpartum doula training.
  • Attendance at a minimum of one (1) breastfeeding class.
  • Attendance at a minimum of two (2) childbirth classes.
  • Attendance at a minimum of two (2) childbirths.
  • Submission of one (1) position paper/essay surrounding the role of doulas in the birthing process.
  • Completion of cultural competency training.
  • Completion of a doula proficiency exam.
  • Completion of HIPAA / client confidentiality training.

Copy of Doula Pilot Attestation Form

NYS Medicaid Doula Enrollment Process

To enroll as a NYS Medicaid provider, the doula will be required to:

  1. Apply for a National Provider Identification Number (NPI#) at the National Plan and Provider Enumeration System website.
  2. Provide a signed and dated attestation (form provided) of receiving doula training in the above–mentioned core competencies.
  3. Provide a copy of the doula´s training certificate – or – an original signed and dated letter from the doula training organization stating the doula has attended and completed a doula training course (this letter must be on the organization´s letterhead).
  4. Complete and return all required NYS Medicaid Provider Enrollment forms:
    1. NYS Medicaid Enrollment Form (eMedNY form #436801)
    2. Electronic Funds Transfer (EFT) Authorization (eMedNY form #701101)
    3. Electronic Transmitter Identification Number (ETIN) Certification Statement for New Enrollment (eMedNY form #490602)

Doulas will be required to return the signed and dated doula training attestation form, proof of your doula training and all completed NYS Medicaid Provider Enrollment forms to the following address:

Provider Enrollment – Doula Pilot
431 Broadway – Room A129
Albany, New York 12204

Complete enrollment applications accompanied by the above–mentioned documentation will be reviewed by the NYS Department of Health (The Department). If more information is necessary to process the application, the doula will be notified as to what information is needed and where to send it.

A written determination of approval or denial of the submitted application will be sent to the doula. If the application is approved, a confirmation letter containing the doula´s Medicaid Management Information System (MMIS) ID Number, the effective date when doula services may be provided to an enrolled NYS Medicaid member, and other information related to enrollment will be sent to the doula.

For enrollment forms and further enrollment instructions, please visit the NYS Medicaid Provider Enrollment Website.

To address any additional questions regarding Provider Enrollment, please contact 1–800–343–9000 (email: providerenrollment@health.ny.gov) or visit the Provider Enrollment website.

While doulas are required to enroll as a NYS Medicaid Fee–For–Service provider, if a doula wishes to provide services to a member who is enrolled in a MMC plan the doula will also need to apply for participation with that member´s MMC plan.

For additional information on MMC enrollment and/or billing, please contact the member´s MMC plan directly. General contact information for each MMC plan is in Section IV of the manual.

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Section II – Doula Services

Doulas, who are participating with the NYS Medicaid program, will be eligible to bill for up to 4 prenatal visits, support during labor and delivery, and up to 4 postpartum visits.

Reimbursement will not be made for appointments which are not kept or for services not provided in person. Group services are not reimbursable.

Providers are not allowed to balance bill members, payment received is considered payment in full for services rendered.

Noncovered services include, but are not limited to, the following:

  • Travel Time
  • Mileage
  • Phone Calls
  • Text Messages
  • Emails
  • Transportation provided to the member, infant, or family

Scope of Services

Purpose

The purpose of this Scope of Service is to define what services a doula may provide to NYS Medicaid members within the NYS Medicaid program.

This section provides a basic outline of the doula´s role for antepartum, labor and delivery, and postpartum services. While this section provides a list of duties and services, the listings are not all inclusive.

What is a Doula?

A doula, also known as a birth companion, birth coach or post–birth supporter, is a non–medical person who has received training to provide physical, emotional, and informational support to members before, during, and after birth.

Reimbursement for Doula Services

The antepartum period shall be defined as the period between pregnancy confirmation by a qualified medical professional and the time in which the member is in active labor.

The period of attendance at delivery is limited to the visit which results in the actual delivery of the infant. NYS Medicaid will not reimburse the doula for any visit(s) which are considered "false" labor. Any visit for "false" labor is included as part of the labor and delivery fee.

The postpartum period shall be defined as the period up to one year following the delivery and is based on the member´s Medicaid eligibility.

All reimbursable visits must be face–to–face and provided on an individual basis to the member. Visits can be any length of time but are typically a minimum of 20 minutes.

Doulas must fully document all services provided to the member at each antepartum and postpartum visit as well as during labor and delivery.

Documentation must include, but is not limited to, the following:

  • Member´s name,
  • Member´s address,
  • Member´s Client Identification Number (CIN),
  • Date of the visit,
  • Time spent with the member, and
  • Full description of all care and services provided.

Doulas are required to retain such records for audit purposes. For more information please see the Record–Keeping Requirements section of this document. Doulas are subject to all NYS Medicaid provider rules and regulations including Unacceptable Practices.

More information on Unacceptable Practices

Doula Services by Stage of Pregnancy

Antepartum Visits (maximum of 4 billable visits)

Antepartum services may include, but are not limited to, the following:

  • Development of an initiation of trust and discussion of preferred communication methods.
  • Review of the following for potential needs:
    • Does the member´s home environment appear safe?
    • Does the member have equipment needs (crib, car seat, stroller)?
    • Will there be child–care needs at the time of delivery?
    • Are there transportation needs (antepartum and postpartum)?
    • Is there a language barrier and will the member require language interpretation services? For additional information on interpretation services, please see section II, page 11.
  • Review the member´s support system (family, friends, and/or significant other) and if able, obtain the phone number for a family member or support person.
  • Address any concerns that have been communicated to the doula by the member.
  • Begin discussion of a birth plan to be shared with the member´s obstetrician/midwife.
  • Begin discussion of the member´s preferred infant feeding method.
  • Provide information regarding prenatal classes and encourage the member to attend.
  • Identify place of delivery and mode of transportation, if applicable.
  • Talk about the member´s expectation of the birth experience, labor and delivery process and anesthesia.
  • Support and reinforce information provided in prenatal classes concerning labor, delivery, and postpartum care of both the member and the newborn:
    • Review home environment to ensure that it is safe and ready for the newborn.
    • Confirm that there is a car seat available for transporting infant.
    • Encourage infant safe sleeping practices.
    • Offer suggestions for coping strategies in the postpartum period.
    • Revisit the birth plan.
    • Discuss notification of active labor and expectations regarding attendance during the labor and delivery process.
  • Revisit preferred feeding method for the newborn and if breastfeeding, encourage breastfeeding classes. Emphasize the member meets with a lactation consult post–delivery if available at the hospital.

Labor and Delivery Attendance (maximum of 1 billable visit)

By week 37, the doula should have reached out to the hospital or birthing center (if applicable) to introduce her/himself and to explain the doula´s role in the labor and delivery process.

Services provided during labor and delivery may include, but are not limited to, the following:

  • At the member´s request, be present at the birth and remain through the immediate postpartum period.
  • Offer help and guidance on measures for comfort and pain relief such as breathing, relaxation, movement, positioning and comforting touch.
  • Be an advocate. Provide emotional support and act as a facilitator to assist in communication with hospital staff.
  • Provide immediate postpartum support and initiation of breastfeeding, as needed (if applicable and trained to provide such breastfeeding support).

Note: The doula´s attendance at labor will only be reimbursed when resulting in delivery of the infant (“false” labor is not reimbursable).

Postpartum Visits (maximum of 4 billable visits)

Postpartum services may include, but are not limited to, the following:

  • Discuss the birth experience.
  • Discuss importance of postpartum physician/midwife follow up.
  • Ask if the infant´s first wellness checkup has been made and, if not, encourage the member to do so.
  • Encourage member to discuss the immunization schedule with the child´s healthcare provider.
  • Be supportive of preferred infant feeding method. If breastfeeding, provide support (if so trained) with latching and positioning. This service is included in the postpartum visit rate. The doula cannot bill separately for lactation counseling.
  • Offer to assist with some light housekeeping duties.
  • Discuss importance of adequate rest for the member.
  • Assist in prioritizing offers of help from friends and extended family.
  • Assist the member in understanding baby cues and suggest techniques for soothing the baby.
  • Demonstrate and have the member provide a return demonstration of infant care.
  • Educate the member on infant carrying devices available.

Limitations in the Role of the Doula

A doula is not permitted to undertake any of the following and does not:

  • Diagnose medical conditions or give medical advice.
  • Perform any type of clinical task or conduct any type of physical or behavioral assessment or exam.
  • Administer medications.
  • Interfere with medical treatment.

Member Eligibility for Doula Services

The Medicaid pilot program will be implemented through a phased–in approach in order to ensure access to this new benefit. Phase 1 of the pilot launches Erie County on March 1, 2019. The Department continues to work with doulas in Kings County to enroll as Medicaid providers and Phase 2 of the pilot will launch in Kings County when provider capacity is reached.

The length of the pilot will be three years with an end date of 2/28/2022. If a Medicaid eligible pregnant woman engages a doula towards the end of the pilot period, the NYS Medicaid program will continue to pay for services through 2/28/2023.

Doulas can only provide services to Medicaid eligible pregnant women who reside in the following zip codes:

Kings County*: 11201, 11202, 11203, 11204, 11205, 11206, 11208,11209,
11210, 11211, 11213, 11214, 11215, 11216, 11217, 11218, 11219, 11220,
11221, 11222, 11223, 11224, 11225, 11226, 11228, 11229, 11230, 11231,
11232, 11234, 11235, 11236, 11237, 11238, 11239, 11241, 11242, 11243,
11245, 11247, 11249, 11251, 11252, 11256.

Erie County: 14001, 14004, 14006, 14010, 14025, 14026, 14027, 14030,
14031, 14032, 14033, 14034, 14035, 14038, 14043, 14047, 14051, 14052,
14055, 14057, 14059, 14061, 14068, 14069, 14070, 14072, 14075, 14080,
14085, 14086, 14091, 14102, 14110, 14111, 14112, 14127, 14134, 14139,
14140, 14141, 14150, 14151, 14169, 14170, 14201, 14202, 14203, 14204,
14205, 14206, 14207, 14208, 14209, 14210, 14211, 14212, 14213, 14214,
14215, 14216, 14217, 14218, 14219, 14220, 14221, 14222, 14223, 14224,
14225, 14226, 14227, 14228, 14231, 14233, 14240, 14241, 14260, 14261,
14263, 14264, 14265, 14267, 14269, 14270, 14272, 14273, 14276, 14280

*New York City Department of Health and Mental Hygiene (NYCDOHMH) is currently operating a grant funded program, By My Side, in Kings county. By My Side is offering similar services, therefore the following 3 zip codes will be exempt from this pilot program: 11207,11212 and 11233.

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Section III – Billing

Billing Guidance

When billing the NYS Medicaid program for services rendered, the following procedure codes should be used:

Visit Type Procedure Code Diagnosis Code Max Number of Billable Visits
Before Childbirth (Prenatal) Visit(s) 99600 Z32.2 4
Labor and Delivery 99499 Z32.2 1
After Childbirth (Postpartum) Visit(s) 99600 + UA Modifier Z32.3 4

View the doula fee schedule here.

Reimbursement is available up to the maximum number of visits per patient in the chart above. Additional visits for each patient, regardless of the number of doulas, are not reimbursable by NYS Medicaid. If additional services are requested by the member doulas can chose to enter into a private pay agreement with the patient. Please see the February 2014 Medicaid Update for more information.

For additional information on MMC billing, please contact the member´s MMC Plan directly. General contact information for each MMC plan is in Section IV of the manual.

Language Interpretation Services

Reimbursement is available for language interpretation services when necessary, which are provided by a third party. The doula cannot bill for interpretation services provided by her/himself. The doula will bill on behalf of the interpreter and would be responsible for paying the interpreter for services rendered.

To be reimbursed for interpretation services, the service must be provided by an independent third–party vendor (e.g., telephonic interpretation service) whose sole function is to provide interpretation services for individuals with limited English proficiency and communication services for people who are deaf and hard of hearing. It is recommended that such individuals be recognized by the National Board of Certification for Medical Interpreters (NBCMI). The need for this service must also be documented in the medical record.

Interpreter Billing Guidance

When billing the NYS Medicaid program for interpretation services on behalf of the interpreter, the following should be used:

HCPCS Procedure Code Billable Units
T1013 One Unit: Includes a minimum of eight and up to 22 minutes of medical language interpreter services
Two Units: Includes 23 or more minutes of medical language interpreter services

Additional information on interpretation services.

eMedNY

NYS´s Medicaid Management Information System (MMIS), called eMedNY, is a computerized system for claims processing which also provides information upon which management decisions can be made. The NYS eMedNY design is based on the recognition that Medicaid processing can be highly automated and that provider relations and claims resolution require an interface with experienced program knowledgeable people. This approach results in great economies through automation yet eliminates the frustration which providers frequently encounter in dealing with computerized systems.

The eMedNY fiscal agent maintains a Medicaid claims processing system to meet NYS and Federal Medicaid requirements, and performs the following functions:

  • Receives, reviews and pays claims submitted by the providers of health care for services rendered to eligible patients (enrollees).
  • Interacts with the providers through its Provider Services personnel in order to train providers in what the Medicaid requirements are and how to submit claims; responds to provider mail and telephone inquiries; maintains and issues forms, and notices, to providers.
  • Maintains the Medicaid Eligibility Verification System (MEVS).

eMedNY Training Information

eMedNY offers various types of educational opportunities to providers and their staff. Training sessions are available at no cost to providers and include information on claims submission, MEVS, and the eMedNY website.

Fast and easy registration, locations, and dates are available on the eMedNY website.

If a doula is unable to access the internet to register or has questions about registration, please contact the eMedNY Call Center at (800) 343–9000.

ePACES Claim Submission

ePACES is an internet–based program that allows NYS Medicaid providers that have been enrolled as authorized users to submit numerous transactions important for the delivery of Medicaid Services in a HIPAA–compliant electronic format. Through ePACES, doulas may submit the following transactions:

  • Professional claims in real–time* or batch**
  • Claim status requests**
  • Member Eligibility Verification.

* Real–time means that the claims are processed instantaneously, and the provider can view the status of a real–time claim within seconds. There is no need to wait for a remittance statement to be mailed to find out about the status of submitted claims.

** Batch means that multiple claims may be saved throughout the day and submitted in a single electronic ´batch´ to eMedNY. The status of claims (paid, pended or denied) submitted via the ePACES batch feature is generally available within 24 hours.

ePACES User Requirements

To enroll in ePACES, providers require the following:

  • A computer with (1) internet access; (2) an internet browser that supports 128–byte encryption; and (3) a Microsoft Windows, Macintosh, or Linux operating system
  • A valid email address
  • An active NYS Medicaid Provider ID Number
  • An active Electronic/Paper Submitter Identification Number (ETIN)

Contact the eMedNY Call Center at 1–800–343–9000 to begin the ePACES Enrollment process.

ePACES Resources

Training for setting up ePACES accounts and submitting transactions through the application is available from eMedNY Regional Representatives. Visit here to find a webinar or seminar near you.

A series of Quick Reference Guides are available at www.eMedNY.org to offer step–by –step instructions for how to submit doula claims and eligibility transactions via the Self–Help page.

Additional general information on how to submit and be paid for services rendered to eligible Medicaid members can be found in the Provider Enrollment Guide

For additional ePACES claim submission and billing guidance, please visit the Doula Provider Billing Manual.

Paper Claim Submission

Doulas who wish to submit their claims on paper forms must use the NYS eMedNY–150003 claim form. To order 150003 forms, contact the eMedNY call center at 1–800–343–9000.

An Electronic/Paper Transmission Identification Number (ETIN) and a Certification Statement are required to submit paper claims. They qualify the provider to submit claims in both electronic and paper formats.

Information about these requirements is available at www.emedny.org by clicking on the link to the webpage.

Note: Providers who have a valid ETIN for submitting electronic claims (including through ePACES) do not need an additional ETIN for paper submissions.

Since the information entered on the claim form is captured via an automated data collection process (imaging), it is imperative that entries are legible and placed appropriately in the required fields.

The addresses for submitting claim forms are:

eMedNY
PO Box 4601
Rensselaer, NY 12144–4601
Expedited/Priority Shipping
eMedNY
327 Columbia Turnpike
Attn: Box 4601
Rensselaer, NY 12144

For additional paper claim guidance, including example forms, please visit the Doula Provider Billing Manual.

Confidentiality

All doulas providing services to Medicaid members must adhere to all confidentiality requirements that apply to medical records including, but not limited to, the following laws and regulations:

45 Code of Federal Regulations (CFR), Part 160 and 164 addresses the standards which protect the privacy of individually identifiable health information.

Additional information on 45 CFR, Part 160 and 164.

42 CFR, Part 2 addresses the circumstances under which lawful holders and legal representatives, contractors, and subcontractors may use and disclose patient identifying information for purposes of payment, health care operations, audits and evaluations.

For additional information on 42 CFR, Part 2: https://www.federalregister.gov/documents/2018/01/03/2017–28400/confidentiality–of–substance–use–disorder–patient–records

NYS Public Health Law (PHL) Article 27–F protects the confidentiality and privacy of anyone who has been tested for HIV, been exposed to HIV, HIV infection or HIV/AIDS–related illness, or been treated for HIV/AIDS–related illness.

Additional information on NYS PHL Article 27–F:

Mental Health Law (MHL), Section 33.13 addresses a provider´s duty to keep sufficient records of a patient´s treatment which cannot be released without the consent of the patient.

Additional information on MHL, Section 33.13.

Record–Keeping Requirements

The Department requires that records of Medicaid members must be kept confidentially, maintained and be available to authorized Medicaid officials.

  • FFS records must be maintained for six years following the date of payment and fully disclose the care, services and supplies provided to the individual.
  • Medicaid Managed Care (MMC) plans are required to maintain medical records for ten years after the date of service, and in the case of a minor, for ten years after the date of service or three years after majority, whichever occurs later. Therefore, MMC plans may require in–network Doulas to maintain medical records for ten years after the date of service, and in the case of a minor, for ten years after the date of service or three years after the majority, whichever occurs later. Doulas must verify record– keeping requirements for each MMC plan they contract with.

Failure to conform to these requirements may affect payment and may jeopardize eligibility to continue as a Medicaid provider.

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SECTION IV – RESOURCES

County Plan Name Contact Number
Erie County
MMC Plans		 Univera Healthcare (800) 920–8889
Fidelis Care New York, Inc. (800) 749–0820
HealthNow New York, Inc (716) 887–6900
Independent Health's MediSource (800) 736–5771
United Healthcare Community Plan (877) 842–3210
WellCare of New York (800) 288–5441
YourCare Health Plan (800) 683–3781
Kings County
MMC Plans		 Affinity Health Plan (800) 553–8247
Empire BlueCross BlueShield Health Plus (800) 454–3730
Fidelis Care New York, Inc. (800) 749–0820
HIP (Emblem Health) (646) 447–5000
Healthfirst PHSP, Inc. (866) 463–6743
MetroPlus (800) 597–3380
United Healthcare Community Plan (877) 842–3210
WellCare of New York (800) 288–5441

*The Medicaid pilot program will be implemented through a phased–in approach in order to ensure access to this new benefit. Phase 1 of the pilot launches Erie County on March 1, 2019. The Department continues to work with doulas in Kings County to enroll as Medicaid providers and Phase 2 of the pilot will launch in Kings County when provider capacity is reached.

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