I am writing this to share the information I have learned as a military spouse seeking reimbursement from Tricare Standard for my home births. Please feel free to share. This is for informational purposes only and is not advice. I have had one birth covered 65% and another claim denied. The birth I had covered was with a Cerified Professional Midweife (CPM) in 2009 in Florida. I did not know in advance what would be covered. She filled out the claim for me after the birth and I was reimbursed 65%. I don't know how or why that worked.
The birth for which the claim was denied was in Virginia in 2012 and also with a CPM. Although I called Tricare many times, I never recieved anything in writing regarding the claim. I was told verbally that it was declined because my provider was not "Tricare authorized." The last person I spoke with at Tricare told me that Tricare does not cover "lay midwives" or "CPMs" when I called to inform them that my type of provider was not listed on their forms. She said the reason they do not cover CPMs is because not all states license them. I reiterated that my midwife is a Licensed Midwife in my state and doesn't Tricare cover the birth of my baby? That rep told me to have my midwife fill out the CNM form and they will re file my claim. My midwife could not fill out that form because the information it asks for doesn't apply to her, so my claim was effectively denied. Win for Tricare, loss for me.
I have spoken to Tricare reps many times over the phone and understand the claims process pretty well. I know many military families just don't want to deal with figuring out what to do to even start filing a claim so they resign to not getting reimbursed. If we do nothing, nothing will ever change, so I am outlining the process for you here. Chances are that you will not get reimbursed, but if you know what to do, filing the claim is simple and maybe eventually we can affect change.
Many insurances companies pay up front for healthcare services from CPMs. Tricare can be one of them, I hope. It is not the location of birth that matters, it is the health care provider. For Tricare to cover services by a particular health care provider, that provider must be "Tricare authorized." Certified Nurse Midwives (CNMs) are Tricare authorized if they are also Registered Nurses and they fill out the Provider Credentialing form from Tricare.
If you have had or are planning to have a homebirth, these are the steps you can follow to file a claim with Tricare. You have one year from the date of service to file claims. This is for homebirth with CPMs in states where they are licensed, although this process would be the same for a CNM if you were filing for reimbursement. Some CNMs may bill Tricare directly, although not many practice homebirth. I don't know of a way to try to get reimbursed if you are on Tricare Prime. The only thing I can think of is if your PCM wrote you a referral to the midwife prior to you starting prenatal care with her.
1. Have your CPM submit a Provider Credentialing form to Tricare. This can be found on mytricare.com. Click "Providers" then "Forms" and use the one for nurses and CNMs. This is how providers become Tricare authorized. Alternately, she may try submitting a copy of her W9 and a copy of her state license.
2. Have your CPM fill out Health Form 1500. This is also on mytricare.com in the provider section.
3. You as the patient go to mytricare.com and find the form under "file a claim."
4. You as the patient mail Health Form 1500 and your claim form to the appropriate Tricare region office. Those addresses are on mytricare.com.
5. Call often. Ask what information they need to process your claim when it gets held up. Avoid giving too much information, just ask what they need from you.
6. There is an appeals process for rejected claims. I didn't go through that process since officially my claim wasn't really denied, they just kept saying that it was basically on hold because my midwife needed to fill out the credentialing form to become Tricare authorized. Please let me know if you have experience with the appeals process.
All insurance companies should cover prenatal, delivery, and postpartum care with licensed midwives. Military families should not be denied coverage.
If you have experience with Tricare and hombirth, please share it in the comments section!
The birth for which the claim was denied was in Virginia in 2012 and also with a CPM. Although I called Tricare many times, I never recieved anything in writing regarding the claim. I was told verbally that it was declined because my provider was not "Tricare authorized." The last person I spoke with at Tricare told me that Tricare does not cover "lay midwives" or "CPMs" when I called to inform them that my type of provider was not listed on their forms. She said the reason they do not cover CPMs is because not all states license them. I reiterated that my midwife is a Licensed Midwife in my state and doesn't Tricare cover the birth of my baby? That rep told me to have my midwife fill out the CNM form and they will re file my claim. My midwife could not fill out that form because the information it asks for doesn't apply to her, so my claim was effectively denied. Win for Tricare, loss for me.
I have spoken to Tricare reps many times over the phone and understand the claims process pretty well. I know many military families just don't want to deal with figuring out what to do to even start filing a claim so they resign to not getting reimbursed. If we do nothing, nothing will ever change, so I am outlining the process for you here. Chances are that you will not get reimbursed, but if you know what to do, filing the claim is simple and maybe eventually we can affect change.
Many insurances companies pay up front for healthcare services from CPMs. Tricare can be one of them, I hope. It is not the location of birth that matters, it is the health care provider. For Tricare to cover services by a particular health care provider, that provider must be "Tricare authorized." Certified Nurse Midwives (CNMs) are Tricare authorized if they are also Registered Nurses and they fill out the Provider Credentialing form from Tricare.
If you have had or are planning to have a homebirth, these are the steps you can follow to file a claim with Tricare. You have one year from the date of service to file claims. This is for homebirth with CPMs in states where they are licensed, although this process would be the same for a CNM if you were filing for reimbursement. Some CNMs may bill Tricare directly, although not many practice homebirth. I don't know of a way to try to get reimbursed if you are on Tricare Prime. The only thing I can think of is if your PCM wrote you a referral to the midwife prior to you starting prenatal care with her.
1. Have your CPM submit a Provider Credentialing form to Tricare. This can be found on mytricare.com. Click "Providers" then "Forms" and use the one for nurses and CNMs. This is how providers become Tricare authorized. Alternately, she may try submitting a copy of her W9 and a copy of her state license.
2. Have your CPM fill out Health Form 1500. This is also on mytricare.com in the provider section.
3. You as the patient go to mytricare.com and find the form under "file a claim."
4. You as the patient mail Health Form 1500 and your claim form to the appropriate Tricare region office. Those addresses are on mytricare.com.
5. Call often. Ask what information they need to process your claim when it gets held up. Avoid giving too much information, just ask what they need from you.
6. There is an appeals process for rejected claims. I didn't go through that process since officially my claim wasn't really denied, they just kept saying that it was basically on hold because my midwife needed to fill out the credentialing form to become Tricare authorized. Please let me know if you have experience with the appeals process.
All insurance companies should cover prenatal, delivery, and postpartum care with licensed midwives. Military families should not be denied coverage.
If you have experience with Tricare and hombirth, please share it in the comments section!
As the actual active duty member it seems like Im not entitled to anything. Any ideas on how to get out of the naval hospital for my first birth?
ReplyDeleteI know one AD mom who had two out of naval hospital births, one at a civilian hospital and one at home. She got someone at the naval hospital to sign off on it. I know another AD mom who tried to do the same thing and was told no. That's all I know, unfortunately. If you find a way to have your baby out of naval hospital, please let us know!
ReplyDeleteUnfortunately, AD folks are at the mercy of the Army, Navy, AF or Marines...The Regulations specifically state for the Army that they are required (no kidding) to receive treatment in an MTF. If they get someone to sign off and anyone figures it out...geesh. Now, the Tricare and now UHC handbook specifically now states care "from a CNM" and no longer just "midwife" and they want provider licensing numbers. I am a CNM and every time we call for a patient, we get a different answer. I am the only CNM who does homebirth for many counties and I do serve the local Army post. Once the switchover to UHC happened...it has been awful. Reimbursement has been anywhere from $1600 to $2100...to nothing. So if we can all put our heads together to figure this out, EVERYONE can get the birth they want.
ReplyDeleteIf anyone wants to contact me with any options or help.... terina@safejourneysmidwifery.com
ReplyDeleteJust wondering if you have a follow up on this? I will be using this info in hopes I can get a little covered as well. Thank you!
ReplyDeleteShelby, I do have an update and need to edit this! My claim was denied. I never got a letter, but the told me over the phone. They denied my midwife's paperwork requesting to be a tricare authorized provider. I wanted to appeal it and take this further with tricare, but I haven't felt motivated to do it. Good luck with your claim! Submitting claims is always worth doing. Never know when it will make a difference.
ReplyDeleteHi, thanks for the info. Would you know what the process would be or what would change when the plan is with tricare prime?
ReplyDeleteThanks!
Evie's Mama, I don't know of a way to try to get reimbursed if you are on Tricare Prime. The only thing I can think of is if your PCM wrote you a referral to the midwife prior to you starting prenatal care with her.
ReplyDeleteDo you know anyone who has had a home birth overseas covered by Tricare? Women in Korea are repeatedly getting denied.
ReplyDelete