You’re now a Traditional Healthcare Worker Doula ready to accept OHP doula clients.

Now what?

Here are the steps to take before & after you accept your first Oregon Health Plan birth doula client.

Please note that I am not affiliated with OHP/OHA other than being a THW myself. I have created this outline to help other THW doulas because I have found the process to be long and confusing. I want to help other doulas to accept OHP birth clients so that all birthing people may have the support they need.

Updated: 1/13/2025

Preparing to Accept OHP Clients

1. You must have the following to proceed: THW certification, NPI, medicaid ID number
2. As of this writing (4/10/2023), the CCOs I have contacted are not creating contracts with doulas anymore. Previously it was recommended to obtain a contract with each individual CCO to ensure you will be paid the contracted amount before you attend the birth and send off the claim form. Contract is no longer necessary.
3. It’s still good to reach out to the THW Liaison for the CCO that your birth client belongs to. The Liaison is an individual that can be your point of contact if you have questions along the way. Get to know them. A smaller CCO might have a call or a zoom meeting with you. Otherwise email introduction is fine.
4. Ask the THW Liaison if they have a doula enrollment form to make billing go smoothly. This will help your claim to be processed faster if you are already in their system. The CCOs I know have an enrollment form are:
   • Health Share Care Oregon
   • Columbia Pacific
5. Collect the following information from the client before services are rendered. This information is required on the claim form.
   • Legal name as listed on their insurance card
   • Home address listed on file with their CCO
   • Date of birth
   • Phone number
   • Birth location
   • Member ID listed on their insurance card
   • LMP Last Menstrual Period (this is used for box 14 on the claim form, Date of Current illness, injury, or pregnancy LMP)
   • Photo of the front and back of their insurance card for your records
6. Open Card: this is a member who does not have a CCO assigned. WARNING! You need to be categorized as a “Fee For Service Provider” to receive payment for Open Card clients. When you are accepting people who have a CCO, you are considered to be a “Managed Care Provider.” In this situation you want to be categorized as both. If you are not a FFS provider, your open card claim will be denied.
   • Email the following:
   • Hello! I am a THW doula and I would like to make sure that I am categorized as a Fee For Service provider AND a Managed Care Provider. I have a member who is pregnant and would like me to attend their birth as their birth doula. This member has Open Card, so I need to make sure my claim will be approved as a Fee For Service Provider before I accept this member as my birth client. Thank you, (Name and NPI#, Medicaid ID#, THW#)
   • Send to: Provider.enrollment@odhsoha.oregon.gov
7. Check member eligibility
   • when you accept the client
   • again when their due date is getting closer (36-37 weeks)
   • You can do this online using your provider portal or by calling OHA.
     • OHA will send you login information for the Provider Portal when you complete your THW registration. Here is the Provider Portal link.
     • Enter in the client’s information:
       • Name, DOB, Member ID, From DOS (today’s date) To DOS (today’s date)
       • Enter in the procedure code you wish to check eligibility for. For example, enter in T1033 in the “Procedure” box
       • On the lookup page, find the text that says “No Service Limitations found for Procedure Code T1033” and you will know your client is eligible for doula support services
   • TPL (third party liability) AKA Private Insurance: is there another insurance listed under TPL in the client record in the provider portal? This means that the client has private insurance as their primary and OHP as their secondary.
     • OHP providers are required to bill the primary insurance first before billing OHP.
     • However, as far as I am aware of, there are no private insurance companies in existence that cover birth doula support.
     • To do your due diligence, you should contact the primary insurance company to confirm that the billing code is not covered.
     • Keep a record of this contact either via email, a denial EOB paper, or record of your phone call and who you spoke to at the private insurance stating that the doula support billing code is not covered by their private insurance.
     • You will need to include “NC” (non covered) in Box 9 of Form 1500. When they key in NC, it tells the system it is not covered by the primary insurance so that OHP will pay your claim.

Accept Your First OHP Client & Attend Their Birth

Bundled Birth Doula Support
The standard bundled birth doula support package through OHP includes 2 prenatal visits, labor/birth support, and 2 postpartum visits for $1500. Make this obligation clear to the client so they know the visit schedule and what to expect.

Individual Support Visits
You can also bill individually for just the visits, or just the birth. For example, maybe you attended their prenatal and postpartum visits but missed the birth. Or, maybe you only attended the birth as a backup but had not completed any prenatal visits. You can bill for each one individually if it does not fit into the Bundled Birth Doula Support parameters.

New in 2025: Additional Support Visits Available
Beginning January 1, 2025 OHP approved additional support visits beyond what is included in the bundle. In this situation, you could bill for the Bundled Birth Doula Support and then individually bill for additional visits as well. There are now 8 visits total approved. So you could include 4 visits within the bundled line item, and then an additional 4 visits may be billed as a separate line item; 8 total.
$1500 (2 prenatal, labor/birth support, 2 postpartum)
$215 third prenatal visit
$215 fourth prenatal visit
$215 third postpartum visit
$215 fourth postpartum visit
= $2,360 maximum possible to bill

These visits could be utilized by having you attend a provider visit with them, or if they needed support through an ECV for a breech baby, helping to meal prep freezer meals, helping in the postpartum with practical items like running laundry, doing dishes, helping cook meals, basic lactation support, being a listening eye and ear for postpartum mood disorders with referrals, etc.

These additional visits are optional and not required.

See: January 2025 Doula Billing Guide PDF

Time Limitations to Additional Support Visits: 6-12 months
OHA Open Card clients can use these visits within 12 months after birth.
Columbia Pacific CCO confirmed to me via email 1/16/2025 that these visits can be used within 12 months after birth when billing the Columbia Pacific CCO. (Susan Palmer, Traditional Health Worker Liaison, colpacthwliaison@careoregon.org)
Other CCOs (Health Share, etc) may be limited to use within 180 days after birth (6 months). This is unclear right now (1/13/25), please contact the individual CCO to see what limitations might exist for your specific client when planning additional support visits postpartum. I emailed Health Share and am waiting to hear back.

Send in Your Claim – Paper Form CMS 1500

1. Complete the CMS 1500 form, print, sign it, and mail it in to the Claims Address for that specific CCO.
   • Columbia Pacific: I have received payment 60 days after submitting my claim as of April 2023.
   • Health Share Care Oregon: I have received payment 12 weeks after submitting my claim as of July 2023.
   • I mail in the claim form the day after the birth.
2. Mistakes on this form can cause your claim to be denied or returned for errors. Double, triple check that you have completed this form correctly!!!
3. Box 9: if the client has private insurance who has denied the doula support claim, include “NC” in Box 9. See section on TPL above for more information on private insurance coverage. Otherwise, skip this box.
4. Box 12: Patient signature. Write SOF (signature on file) and include today’s date.
5. Diagnosis Code (box 21A).
   Get a list of relevant diagnosis code and procedure codes for the claim form.
   • Diagnosis Codes can be found on the most up to date Prioritized List, here.
   • It’s not our place as doulas to diagnose, so it’s frustrating that this is a required field. I hope in the future it will not be a required field for doulas.
   • Common Diagnosis Codes are:
   • FIRST PREGNANCY
     • Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester),
     • Z34.01 (… first trimester),
     • Z34.02 (… second trimester),
     • Z34.03 (… third trimester).
   • ANY NUMBER PREGNANCY
     • Z34.90 (Encounter for supervision of normal pregnancy, unspecified trimester),
       • Z34.91 (… first trimester),
       • Z34.92 (… second trimester),
       • Z34.93 (… third trimester) frequently used
   • Twins
     • 030.00 – Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs
   • Postpartum Follow Up
     • Z39.2 – Encounter for routine postpartum follow-up
   • One possibly useful diagnosis code?
     • Z87.59 – Personal history of other complications of pregnancy, childbirth and the puerperium
   • Source – Prioritized List
6. Bundled Birth Procedure Code (box 24D).
   • As of 7/1/24, you no longer have to use a different procedure code depending on whether it is a vaginal birth, cesarean, VBAC, etc. There is now one procedure code regardless of the mode of delivery.
   • Bundled (2 prenatal visits, birth, 2 postpartum visits):
     T1033 Modifier: HD
     Global doula benefit with support at delivery
7. Partial Service Procedure Codes (box 24D).
   • Itemized support visits or itemized birth support (when you just do one without the entire bundle)
   • Use T1033 without modifier
     $215 each
     Support visit (each visit, up to 8 total; can be prenatal or postpartum visits)
     If you’ve already billed for 4 visits in the bundled birth procedure code, there is an additional 4 visits maximum available to bill
   • Use T1033 Modifier: 22
     Doula services day of delivery only: $645
8. Place of Service Codes: (box 24B)
   • 25, Birth Center
   • 12, Home
   • 21, Inpatient Hospital
   • Source
   • Unapproved place of service code is one reason some claims could be denied, make sure the place of service code on your claim is correct.
9. Box 24E, Diagnosis Pointer: enter A (this corresponds to what you entered in box 21A/B/C)
10. Box 24F, Charges:
    • enter $1500 for bundled birth support (bundle = 2 prenatal visits, birth support, 2 postpartum visits)
    • enter $215 for each visit if billing for itemized support; can be prenatal or postpartum visits.
      If you’ve already billed for 4 visits in the bundled birth procedure code, there is an additional 4 visits maximum available to bill (8 total)
    • enter $645 for labor/birth support, if billing for itemized support
11. Box 24J, Rendering Provider ID#: Enter your NPI
12. Complete form CMS 1500 electronically, print it out, sign it, put it in an envelope and mail it to the claims address for the CCO of your client.
13. If your claim is denied, resubmit it after fixing errors.

To Recap, New Procedure Codes Are (updated 1/13/25)

Here is an EXAMPLE CMS 1500 PDF form (you need to fill out all your own information) showing which fields are required.

Here is a list of Required Fields on CMS 1500.

Here is the official OHA Doula Billing Guide Jan 2024.pdf

Claims Addresses

You can find the claims addresses on the CCO’s website.

Here are some of the claims department addresses I have collected so far.

Health Share Care Oregon
Claims Department
PO Box 40328
Portland OR 97240

Columbia Pacific CCO
C/O CareOregon Claims
PO Box 40328
Portland, OR 97240

OHSU
PO Box 40384
Portland, OR 97240
(HealthShare/OHSU Claims)

Questions

It’s best to reach out to the THW Liaison for that CCO if you have questions. The THW Liaison can often be found on that CCO’s website. Here are the THW Liaison email addresses I have collected.

Yamhill CCO THW Liaison – providerrelations@yamhillcco.org
Columbia Pacific THW Liaison – colpacthwliaison@careoregon.org
Columbia Pacific Provider Relations Specialist – colpacprs@careoregon.org
Open Card questions – provider.enrollment@odhsoha.oregon.gov

Health Share has five different Health Plans (CareOregon, OHSU Health, Providence, Kaiser, and Legacy PacificSource):
Health Share THW Program – thw.info@healthshareoregon.org
Heath Share CareOregon THW Liaison – metrothw@careoregon.org
Health Share OHSU – ransome@ohsu.edu

If you are having trouble getting the help you need, Mohamed Abdiasis is the THW Program Manager and his email is ABDIASIS.MOHAMED@dhsoha.state.or.us

Check Claim Status

After submitting a claim, you can log in to the Provider Portal to check the status of your claim.

Enter the Client ID, FDOS and TDOS (from and to date of service; aka the day of the birth as you included it on the claim)

Disclaimer

Please note that I am not affiliated with OHP/OHA other than being a THW myself. I have created this outline to help other THW doulas because I have found the process to be difficult or confusing. I want to help other doulas to accept OHP birth clients so that all birthing people may have the support they need.

Thank you to the other doulas I am in contact with for sharing what has and has not worked on claim forms. I am extremely grateful to be in community with you.

If you have anything to add to make this guide better, please email me at nataliebroders@gmail.com.