Maternity care involves the medical services related to prenatal care, labor and delivery, as well as postpartum care. Any woman eligible for TRICARE benefits can receive maternity care from the first obstetric (OB) visit through up to six weeks after the birth of the child. This includes spouses, eligible former spouses, spouses of retirees and TRICARE-eligible unmarried children of active duty service members (ADSMs).

Referrals and Authorizations

If you are the primary care manager (PCM) for a beneficiary who becomes pregnant, you’ll need to either refer her to an obstetrics (OB) specialist or, if you are going to manage the pregnancy, handle the prior authorizations necessary throughout her pregnancy. Obstetric services require a prior authorization from Humana Military, which should be obtained at the mother’s first appointment with you (the PCM) about the pregnancy. The prior authorization will begin with the first prenatal visit and remain valid until 42 days after birth. Prior authorization must be obtained for both inpatient and outpatient services.

If your patient is enrolled in TRICARE Prime and intends to deliver in a civilian (non-MTF) facility or birthing center, a separate prior authorization for the delivery portion of her maternity care must be obtained. The separate prior authorization should be obtained as soon as her pregnancy is confirmed.  Visit the online tutorial for Referrals and Authorizations to learn more.

• Services and supplies associated with prenatal, childbirth, postpartum care and complications
• Epidural anesthesia for pain management during delivery
• An ultrasound, if medically necessary, (within the maternity care global fee). Determining gender is not considered medically necessary. Maternity ultrasound is covered (outside the global fee) only with diagnosis and management of conditions that constitute a high-risk pregnancy.
• TRICARE-certified/authorized birthing centers
• Emergency Cesarean section
• Circumcision

• Maternity inpatient stays (length of stay benefit cannot be restricted to less than 48 hours following a normal vaginal delivery or 96 hours following a Cesarean section)
• Planned Cesarean section and tubal ligation

• Services and supplies related to noncoital reproductive procedures (artificial insemination, etc.)
• “Routine” ultrasounds are not covered. If a provider or beneficiary wishes to perform a “routine” ultrasound, it will not be covered in addition to or separately from the global maternity benefit. Beneficiaries can choose to pay for a routine ultrasound separately from their TRICARE benefits if they complete a “Request For Non-Covered Services Form” prior to the service being rendered.
• Off-label use of FDA-approved drugs to induce or maintain tocolysis
• Home Uterine Activity Monitoring (HUAM), telephonic transmission of HUAM data or HUAM-related telephonic nurse or physician consultation
• Lymphocyte or paternal leukocyte immunotherapy for the treatment of recurrent spontaneous fetal loss
• Salivary estriol test for preterm labor
• Personal comfort items such as private rooms and televisions after delivery

TRICARE requires all network providers to file claims electronically. For assistance with any issues related to electronic media claims (EMC) submission for the TRICARE South Region, you can contact the PGBA EMC Help Desk at 1-800-325-5920, option 2.

You may also visit Humana Military's Web site or My TRICARE for more information regarding electronic claims submission.

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