TRICARE Childbirth and Breastfeeding Support Provider Reimbursement
The information on this page serves as a comprehensive guide for providers regarding coverage and reimbursement policies for the TRICARE Childbirth and Breastfeeding Support Demonstration. This includes allowable visits, billing procedures, and necessary qualifications.
TRICARE covers specific support services related to childbirth, facilitating both antepartum and postpartum care, as well as continuous labor support. Additionally, lactation specialists can provide breastfeeding support services with specific guidelines for reimbursement.
Childbirth Support Services Reimbursement for Certified Labor Doula
TRICARE will cover up to six hours of visits timed per 15-minute increments by a Certified Labor Doula (CLD) at no additional cost to the beneficiary. These visits can be before or after the patient gives birth. The patient will also receive one visit during birth. Any non-network doulas must meet CBSD qualifications outlined under TRICARE.
TriWest requires all CLDs delivering care to be participating providers. To be eligible for reimbursement for dates of service on or after January 1, 2025, both network and non-network providers must have a signed participation agreement prior to delivering services. They must agree to file claims and accept TRICARE reimbursement as payment in full for services rendered on or after January 1, 2025.
The CLD designation to be used is 374J00000X Certified Labor Doula.
Antepartum and Postpartum Support Visits
Antepartum and postpartum support visits are timed per 15-minute increments. Providers shall bill a maximum of 24, 15-minute increments combined for antepartum and postpartum visits per birth event. The provider shall bill antepartum and postpartum support visits using CPT code T1032.
Continuous Labor Support
The continuous labor support visit is untimed. The provider shall bill the continuous labor support visit with CPT code T1033 and must bill only one continuous labor support visit per birth event regardless of the length of labor, and regardless of whether the delivery is vaginal, C-section, or the labor results in a live birth.
The provider shall not bill additional amounts for travel to the delivery location or travel with the patient to move from an initial location (the home or birthing center) to another location (a hospital), for long or difficult deliveries, or for false labor.
Summary of Childbirth Support Services - CLDs
| Participation Agreement | Required |
| Reimbursement | Phase 2 reimbursement only |
| Balance Billing | Not permitted |
| Beneficiary Costs | $0 |
| Antepartum/Post-Partum Visit Allowances | 24, 15-minute visit increments billed using CPT code T1032 |
Download the Doula Phase 2 Rates: Download the file for the year in which services were delivered; rated are valid from March 1 until end of February fo the following year.
Reimbursement for Lactation Consultants/Counselors
The lactation consultant/counselor shall bill for services under the breastfeeding support portion of the demonstration but shall not bill for any other services performed by a lactation consultant or lactation counselor.
The lactation consultant/counselor and other TRICARE-authorized providers must verify that all claims for breastfeeding support services under the demonstration include the appropriate Health Insurance Portability and Accountability Act (HIPAA) taxonomy designation of each provider type. The designations to be used are:
- 163WL0100X Lactation Consultant (if a registered nurse)
- 174N00000X Lactation Consultant (if not a registered nurse)
- 174400000X Lactation Counselor (if the National Uniform Claims Committee creates a taxonomy designation specific to lactation counselors, that taxonomy designation shall be used).
- Other appropriate HIPAA taxonomy based on license/certification.
If services were provided via telehealth, include the appropriate modifier (either GT or 95).
Individual Lactation Consulting
Individual Lactation Consulting sessions timed per 15-minute increment using the following CPT codes:
- CPT code 99401 – 15 minutes
- CPT code 99402 – 30 minutes
- CPT code 99403 – 45 minutes
- CPT code 99404 – 60 minutes
Group Lactation Consulting
Group Lactation Consulting sessions timed per 30-minute increment using the following CPT codes:
- CPT code 99411 – 30 minutes
- CPT code 99412 – 60 minutes
Lactation Rates: (rates vary by locality)
Visit the Lactation Rates page and follow the steps below:
- Step 1: Add locality
- Step 2: Choose, CMAC and Component (Locality dependent)
- Step 3: effective period, choose “Current”