Doula claim submission FAQ

This document provides detailed guidance on the electronic submission of doula service claims. It includes information on Availity Essentials, training resources, claim form requirements, and coding for Medicaid reimbursements.

Q: How are claims submitted?

A: Claims are submitted by electronic data interchange (EDI). Care providers may submit claims, eligibility inquiries, claim status inquiries, and associated attachments using EDI by being a trading partner (TP) authorized by the State Agency or by contracting with an ODM‑authorized TP.

Regarding Availity Direct Data Entry (DDE) claim submission, care providers must send claims electronically through ODM’s Fiscal Intermediary (FI) through Direct Data Entry on Availity Essentials, which will pass provider claims to us for processing. Claims submitted correctly the first time are called clean, meaning all required fields have been completed and the correct form was used for the specific type of service provided.

Q: Are paper claims accepted?

A: No

Q: What is Availity Essentials?

A: Availity Essentials, https://Availity.com, is an engagement platform for payers (insurance companies) and care providers (doctors, hospitals, and so on). It serves as a secure and reliable hub to facilitate communication and transactions between these two parties in the healthcare industry. Availity Essentials aims to simplify and automate various processes, such as eligibility, claims submission, disputes, and prior authorization requests.

Q: Does Availity Essentials require registration?

A: Yes. Availity Essentials is open to care providers at no cost, but registration is required. Additional information on getting started can be found on our care provider learning hub (on24.com).

Q: Does Availity Essentials offer training?

A: Yes, Availity Essentials has self‑paced courses on verifying eligibility, claims submission, submitting disputes, and more. Availity Essentials also offers live trainings throughout the year. Courses can be found on our care provider learning hub (on24.com).

A course for claims submission can be found in Availity Essentials here.

Note: You must be logged in to Availity Essentials to access this content. You must be registered with Availity Essentials to enter claims via Direct Data Entry or to check eligibility, claim status, and so on.

Q: What is a HCFA‑1500?

A: Also known as the CMS‑1500, this is a standardized claim form used by healthcare providers. When you submit a claim on Availity Essentials, this form is automatically filled out and submitted to ODM’s Fiscal Intermediary (ohio.gov) for claims processing.

Q: What is the reimbursement for doula services?

A: The reimbursement is as follows.

T1032:

• Services performed by a doula birth worker per 15‑minute unit
• $12.50 per unit, up to $600
• Up to 48, 15‑minute units at any time from first prenatal visit to 12 months postpartum
• Telehealth services require appending the GT modifier.

T1033:

• Services performed by a doula during member’s delivery
• $600 flat rate, regardless of length of birth

Procedure codes are entered into box 24D on the HCFA‑1500 (Rule 5160-8-43 - Ohio Administrative Code (ohio.gov)).

Q: What diagnosis codes does ODM recommend?

A: ODM recommends these:

• Z34.x:
• Z34.0: Supervision of a normal first pregnancy
• Z34.8: Supervision of another normal pregnancy
• Z34.9: Supervision of a normal pregnancy, unspecified
• Z34.00: Encounter for supervision of a normal first pregnancy, unspecified trimester
• Z34.80: Applicable to female patients aged 12 to 55 years
• Z34.90: Applicable to female patients aged 12 to 55 years
• Z34.83: Applicable to mothers in the third trimester of pregnancy, which is defined as between equal to or greater than 28 weeks since the first day of the last menstrual period:
• O80.0: Spontaneous vertex delivery, which includes cases with minimal or no assistance
• Z37.9 is the ICD‑10‑CM code for an unspecified outcome of delivery.
• Z32.2 is for an encounter for pregnancy testing, childbirth, and childcare instruction.
• Z39.2 is the ICD‑10‑CM diagnosis code for a routine postpartum follow‑up.

Diagnosis codes are entered into Box 21 on the HCFA‑1500

Q: What is Anthem’s Payer ID?

A: Our Payer ID is 0002937.

Q: What is considered timely filing for claims?

A: Timely filing is 365 days from the date of service or date of discharge on the claim unless stated differently in your contract.

Q: How can I enroll for electronic claim payments?

A: Use EFT Enrollment Hub (payeehub.org) to register and manage electronic funds transfer (EFT) account changes.

Helpful links

Doulas (ohio.gov)
Provider website
Claim Form (CMS-1500) (cms.gov)
Place of Service Code Set (cms.gov)

See our representative territory map (PDF) to identify the Provider Rep Terminology in your area.