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: 7/1/2024

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

Accept Your First OHP Client & Attend Their Birth

Attend and document the following: 2 prenatal visits, labor and birth, 2 postpartum visits in order to bill for the entire bundled birth package for $1500. You can also bill visits or birth individually.

Make sure that your client knows you are required to have 2 prenatal visits and 2 postpartum visits to get paid. They want you to get paid by their insurance, so let them know you need to fulfill this obligation.

Send in Your First Claim

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 12: Patient signature. Write SOF (signature on file) and include the date.
4. 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).
   • 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
5. 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
6. 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
     Support visit (each visit, up to 2 prenatal and 2 postpartum visits): $215 each
   • Use T1033 Modifier: 22
     Doula services day of delivery only: $645
7. 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.
8. Box 24E, Diagnosis Pointer: enter A (this corresponds to what you entered in box 21A/B/C)
9. Box 24F, Charges:
   • enter $1500 for bundled birth support
   • enter $215 for each support visit, if billing for itemized support
   • enter $645 for labor/birth support, if billing for itemized support
10. Box 24J, Rendering Provider ID#: Enter your NPI
11. 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.
12. If your claim is denied, resubmit it after fixing errors.

To Recap, New Procedure Codes Are (updated 7/1/24)

• T1033 Modifier HD – bundled birth support, includes two prenatal visits, labor/birth support, and two postpartum visits
• T1033 – Support visit (each visit, up to 2 prenatal and 2 postpartum visits)
• T1033 Modifier 22 – Doula services day of delivery only

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.

Care Oregon THW Liaison – metrothw@careoregon.org
Yamhill CCO THW Liaison – providerrelations@yamhillcco.org
Columbia Pacific THW Liaison – colpacthwliaison@careoregon.org
Open Card questions – provider.enrollment@odhsoha.oregon.gov

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

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 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.

Thank you to the other doulas I am in community with for sharing what has/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.