Provider Notice issued 12/19/2024

This notice informs doulas of certification, enrollment, and billing requirements as Medicaid providers in the Department of Healthcare and Family Services’ (HFS) Medical Programs. Doula services will be covered under the Medicaid fee-for-service (FFS) program and the HealthChoice Illinois (HCI) managed care organizations (MCOs).

In accordance with Public Act 102-0004, HFS pursued coverage of doula services with a State Plan amendment (SPA) submitted to the Federal Centers for Medicare & Medicaid Services. This SPA was approved with a coverage effective date of February 1, 2024. 

Certification

Doulas must obtain a certificate from the Illinois Medicaid-Certified Doula Program, being administered by the Southern Illinois University (SIU) School of Medicine, prior to completing the Medicaid enrollment process with HFS. This program leverages national and Illinois-based training courses. SIU will not charge any fees to doulas. Doulas are encouraged to begin the certification process that is being administered by the SIU School of Medicine if they have not already done so. SIU has published certification information on their website at Illinois Medicaid-Certified Doula Program | SIU School of Medicine (siumed.edu). From this main page, doulas may review:

·         Pathways and Requirements - Pick either the Training Program Pathway or Legacy Pathway, and see requirements needed to apply.
·         How to Apply - See a list of required application items, download the handbook, and submit your application via email, mail, or online.

Once a doula becomes certified through SIU, they will be issued a certificate that confirms that the doula has met all applicable requirements. It contains a unique certification number tied to the doula, with a certificate effective date and expiration date. The certificate must be uploaded during the provider enrollment process with HFS.

The certification is valid for three years; after that, the doula must re-certify through SIU and submit proof of recertification to HFS.

Questions regarding certification may be directed to the SIU School of Medicine at  doulacertification@siumed.edu.

Provider Enrollment through HFS

Doula services are reimbursable to certified doulas enrolled in the Illinois Medicaid Program Advanced Cloud Technology (IMPACT) provider enrollment system. Doulas should review the IMPACT Account Activation Instructions for New External IMPACT Users.

In IMPACT, a doula must select an Enrollment Type of either:

1.)   Rendering/Servicing Provider – An individual provider who will be rendering services to Medicaid customers but will not be submitting claims directly to the State for reimbursement. Enrolling as a Rendering provider requires that you associate with a Group Practice or Facility, Agency, Organization (FAO) as a billing provider in the IMPACT system and would not allow you to bill for yourself.

2.)   Regular Individual/Sole Proprietor – A provider that owns his/her own practice. A Sole Proprietor may receive payments directly or associate to Billing Providers and/or Billing Agents. If you enroll as a Sole Proprietor, you can still also associate with a Group Practice or FAO as your Billing Provider(s) and they may bill on your behalf, but this is optional. You can use this enrollment option to work as part of an organization and/or bill for yourself.

Doulas must have a National Provider Identifier (NPI) in order to enroll. Information about obtaining an NPI is located on the CMS website.

Note Regarding Advanced Practice Registered Nurses: If you are an advanced practice registered nurse who is also a doula, you can bill using Evaluation and Management codes and do not need to enroll under the new provider type.

Note Regarding Clinics: Federally Qualified Health Centers, Rural Health Clinics, and Encounter Rate Clinics will be allowed to bill practitioner claims (instead of medical encounters). For the services listed below, the service must be billed under the enrolled, rendering doula’s NPI with payment directed to the clinic/center’s corporate NPI.

Doula Billable Procedure Codes

Standing Recommendation

The State of Illinois has issued a standing recommendation for doula services. When doulas document the services they deliver, they must note in their documentation that they either (1) used the standing recommendation or (2) used a recommendation from a specific licensed physician, physician assistant (PA), or advanced practice registered nurse (APRN). This documentation is for audit purposes and to meet the federal requirement that preventive services provided by the certified doula be recommended by a licensed provider. This information will only go in the doula’s documentation of services. It will not go on the claim submitted for reimbursement.

Claim Submission

Claim Format

Doula services are billed electronically on the 837 Professional transaction. Information regarding electronic 837P transactions may be found in the Chapter 300 Companion Guide. Claims may also be submitted via direct data entry within the MEDI system. Please note: CPT 59430 is reimbursable only when the doula attends the postpartum visit with a practitioner, and the visit occurs within 26 days from delivery date, and/or between 27-89 days of the delivery date. The actual delivery date must be reported on the claim to receive payment for attendance at the postpartum visit(s), provided the above timelines are met.

Taxonomy Code

Taxonomy code for Doula Services:  374J00000X 

Telehealth

The telehealth delivery method is allowable for patient education codes S9444 and S9445, as well as the doula support during and/or after miscarriage or abortion code T1032, utilizing modifier GT (Via Audio and Video Telecommunications Systems) or 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system) and place of service 02 (Telehealth Provided Other than in Patient’s Home) or 10 (Telehealth Provided in Patient’s Home), as applicable.

Fee schedule

More detail regarding the billable procedures is contained in the Doula Fee Schedule on the Reimbursements page of the HFS website.

Medicaid Provider Educational Materials and Webinars for Doulas

The Medicaid Technical Assistance Center (MTAC), in partnership with HFS, has prepared enhanced Medicaid onboarding educational materials and supports to aid doulas in the enrollment process. This includes a Medicaid provider overview specifically for doulas, how to obtain a National Provider Identifier (NPI), and how to enroll in IMPACT, the Illinois Medicaid provider enrollment system.

Please visit the MTAC Learning Center to register for an MTAC Learning Center account to access the calendar of training dates, times, and registration links. Doulas may also reach MTAC for technical assistance support at mtac.maternalhealth@uillinois.edu.Questions regarding this notice, or requests to schedule a MEDI billing training, may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or the appropriate MCO. 

Kelly Cunningham, Administrator
Division of Medical Programs