How to verify insurance and submit claims for doula services

Doulas provide non-medical support during childbirth, pregnancy, and postpartum recovery.

Doula services are becoming more popular. And insurance coverage for them is too.

Many state Medicaid programs and TRICARE now cover doula services. Some commercial plans and Medicare Advantage plans cover them, too.

But billing for doula services is more complex than billing for a standard physician visit:

• No Service Type Code maps cleanly to doula services for eligibility checks.

• Payer support for doula-related CPT/HCPCS procedure codes varies.

• Prior authorization is often required.

This guide covers how to verify insurance and process claims for doula services using Stedi.

Payer support

Which payers typically cover doula services?

Coverage depends largely on the payer type.

Many states – including Minnesota, Oregon, and New York – have added doula services to their Medicaid programs. But coverage isn’t universal, even within Medicaid.

Always run an eligibility check to verify the patient's benefits before submitting a claim.

How do I find the right payer ID?

Use Stedi’s Payer Network site or our Search Payers API to find payer IDs for eligibility checks, claims, and claim status checks.

Payer ID aliases
If you already use another clearinghouse's payer IDs, you can keep using them with Stedi. We map known payer ID aliases automatically. You don’t need to manually remap them.

Medicaid payer IDs
Payer IDs for Medicaid vary by state. The ID for Minnesota's Medicaid program won't work for New York's.

To avoid errors, look up the correct payer ID for each state program before running a transaction. For example, you can search the Payer Network site or our Search Payers API for “New York Medicaid” or “Ohio Medicaid.”

Insurance verification for doula services

How do I verify insurance for doula services?

For high-volume insurance verification workflows, real-time eligibility checks are the default.

You can run eligibility checks – in real time or batch – using the Stedi portal or Stedi’s Eligibility API.

Other verification options include using a payer portal or calling the payer.

Do I need transaction enrollment to run doula eligibility checks?

Transaction enrollment is the process of registering a provider to exchange specific healthcare transactions with a payer.

While it’s rare with commercial payers, some state Medicaid payers require transaction enrollment for eligibility checks. Without it, they’ll return an AAA error – and no benefits information.

You can use Stedi’s Payer Network site or our Search Payers API to check whether a payer requires enrollment for eligibility and other transaction types.

Which Service Type Codes should I use for doula eligibility checks?

There’s no single Service Type Code (STC) for doula services. Each payer may use a different one. The only way to know is to test STCs with each payer.

For doula services, we recommend testing the following STCs in order:

• BT – Obstetrics

• BU – Obstetrical/Newborn Care

• BV – Well Baby Care

• 1 – Medical Care

If those STCs don't return the benefit data you need, try STC 30 (Health Benefit Plan Coverage). Many payers provide a baseline eligibility response for this STC.

For testing tips, see Test payer STC support.

How do I check for prior authorization requirements?

Many plans require prior authorization, including a prior authorization number, for doula services. In these cases, if you submit a claim without the required prior authorization – including the prior authorization number when applicable – the payer will deny the claim.

Most payers indicate whether prior authorization is required in the eligibility response.

For example, in Stedi’s JSON eligibility responses, most payers include a Y in the related benefit object’s authOrCertIndicator field if prior authorization is required.

{
  "benefitsInformation": [
    {
      "code": "A",                   // Co-insurance
      "serviceTypeCodes": ["BT"],    // Obstetrics
      "authOrCertIndicator": "Y",    // Prior authorization is required
      ...
    },
    ...
  ],
  ...
}

{
  "benefitsInformation": [
    {
      "code": "A",                   // Co-insurance
      "serviceTypeCodes": ["BT"],    // Obstetrics
      "authOrCertIndicator": "Y",    // Prior authorization is required
      ...
    },
    ...
  ],
  ...
}

{
  "benefitsInformation": [
    {
      "code": "A",                   // Co-insurance
      "serviceTypeCodes": ["BT"],    // Obstetrics
      "authOrCertIndicator": "Y",    // Prior authorization is required
      ...
    },
    ...
  ],
  ...
}

An eligibility response can only tell you whether prior authorization is required. It doesn’t request or get the prior authorization.

For more information, see our prior authorization docs.

What if my eligibility response doesn't include doula benefits?

Doula services are a newer benefit for many plans. Some payers don't include doula benefit details in eligibility responses, even if they’re covered.

If your eligibility response is missing benefit data, try the following steps in order:

1. Test different STCs with the payer.
   As a first step, test the STCs recommended above with the payer.
   
   

2. Check the payer portal or call the payer.
   Call or use the payer’s portal to get any missing benefits information you need. You can do this manually or use an AI voice agent or screen scraper to do it programmatically.
   
   

3. Record what you learn.
   Create a system to track the information you get for each payer and plan. Depending on your needs, this could just be a database, spreadsheet, or JSON file.
   
   

4. Use the collected data to enrich your eligibility responses.
   Plan benefits for the same payer and plan usually don’t vary from member to member. You can reuse the information you collect to enrich eligibility responses across patients for that plan.

Even when plan benefits are the same, eligibility checks are still useful for things that change by member, like active coverage or service history.

For more tips, see How to deal with gaps in eligibility responses.

Claims for doula services

How do you submit claims for doula services?

You can submit a professional claim for doula services electronically using the Stedi portal, SFTP, or the following Stedi APIs:

• Professional Claims JSON

• Professional Claims Raw X12

X12 HIPAA format
HIPAA requires that professional claims be exchanged electronically using the 837P X12 EDI format. If you use Stedi’s Professional Claims JSON API, we handle the translation to X12 for you.

Stedi portal
The Stedi portal’s professional claims form lets you submit claims using a user-friendly UI.

The form is designed to mirror the CMS-1500 Health Insurance Claim Form – also called the HCFA – the standard paper form used for professional claims.

What CPT/HCPCS procedure codes are used for doula services?

HCPCS Level II procedure codes T1032 and T1033 apply to some doula services, but payer support for the codes varies. Many payers don't accept them yet.

Always confirm which CPT/HCPCS codes the payer accepts before submitting claims. Using the wrong CPT/HCPCS codes can cause a claim to be denied.

Custom HCPCS codes for doula services
Medi-Cal, the payer for California’s Medicaid program, uses custom HCPCS codes for doula services.

Because these codes are custom to Medi-Cal, they’re not typically accepted by other payers. If you attempt to use them with another payer, the payer may reject or deny the claim.

What place of service code do doulas use?

Place of service codes indicate where a service was delivered.

For doula services, the place of service must match where the birth or other service occurred. Payers often deny claims with the wrong place of service code.

Should doula claims include an admission date?

No. Doulas don’t admit patients. An admission date typically applies to hospital or facility stays, not to doula services.

Some payers may incorrectly reject doula claims for a missing admission date.

If this happens, you can include the admission date to avoid delays. Also, reach out to Stedi. We’ll contact the payer and ask them to correct the issue.

What happens after you submit a claim?

Doula claims follow the standard claims lifecycle:

1. Stedi validates the claim.
   If it fails validation, Stedi rejects it before sending it to the payer. Correct the errors and resubmit.
   
   

2. The payer receives and adjudicates the claim.
   The payer may accept the claim for processing or reject it. Accepted claims enter adjudication, where the payer decides what they’ll pay the provider.
   
   

3. You receive an ERA.
   Once adjudicated, the payer sends an 835 Electronic Remittance Advice (ERA).The ERA includes information about payment decisions for the claim and each service line item.

You can track the status of a claim using claim acknowledgements and real-time claim status checks. To learn more, see our claim lifecycle docs.

Get started with Stedi

Billing for doula services is still new territory for most payers and RCM teams.

When you run into edge cases, Stedi's support team can help you interpret eligibility responses and work through payer-specific requirements.

To try Stedi, sign up for our free Basic plan. The plan includes 100 free eligibility checks and 100 free claim submissions each month. Signup takes two minutes – and no credit card is required.