Maternity care involves the medical services related to prenatal care, labor and delivery, and postpartum care. Any woman eligible for TRICARE benefits can receive maternity care from the first obstetric visit through up to six weeks after the birth of the child. Women eligible for TRICARE benefits include spouses of ADSMs, certain eligible former spouses, spouses of retired service members, and TRICARE-eligible unmarried children of active duty or retired service members.
Note: A newborn grandchild of an ADSM or retired service member is not eligible for TRICARE unless the newborn is otherwise eligible as an adopted child or the child of another eligible sponsor.
Referrals and Authorizations
If you are the PCM for a beneficiary who becomes pregnant, you will need to either refer her to an obstetrician or, if you are going to manage the pregnancy, handle the required prior authorizations throughout her pregnancy. Obstetric services require a prior authorization from Humana Military for TRICARE Prime, TPR, and TPRADFM beneficiaries. The prior authorization should be obtained at the mother’s first appointment with you (the PCM) involving 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.
Additional prior authorization is required for the following maternity-related services:
-
Maternity inpatient stays (length of stay 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
Covered Services
- Emergency cesarean section
- Epidural anesthesia for pain management during delivery
- Hospital-grade breast pumps for mothers of premature infants
- Medically necessary ultrasounds (e.g., to evaluate fetal well-being, growth, or gestational age, or to evaluate or rule out complications). See additional information on ultrasounds later in this section.
- Services and supplies associated with prenatal, childbirth, postpartum care, and complications
- TRICARE-authorized birthing centers
Non-Covered Services
- 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
- Off-label use of FDA-approved drugs to induce or manage uterine contractions
- Personal comfort items such as private rooms and televisions after delivery
- Routine ultrasounds (e.g., to determine the sex of the fetus or for patients with low complication risks). See additional information on ultrasounds later in this section.
- Salivary estriol test for preterm labor
- Services and supplies related to noncoital reproductive procedures (e.g., artificial insemination)
TRICARE Maternity-Related Ultrasounds
The professional and technical components of medically necessary fetal ultrasounds are covered in addition to the maternity global fee. The medically necessary indications include, but are not limited to, clinical circumstances that require obstetric ultrasounds to:
- Conduct a biophysical evaluation for fetal well-being
- Confirm cardiac activity
- Determine the cause of vaginal bleeding
- Diagnose or evaluate multiple gestations
- Estimate gestational age
- Evaluate a suspected ectopic pregnancy
- Evaluate fetal growth
- Evaluate maternal pelvic masses or uterine abnormalities
- Evaluate suspected hydatidiform mole
- Evaluate the fetus’ condition in late registrants for prenatal care
Per American College of Obstetricians and Gynecologists guidelines, ultrasonography should be performed only when there is a valid medical indication. A physician is not obligated to perform ultrasonography for a patient who is at low risk and has no medical indications. Some providers offer all patients routine ultrasound screening as part of the scope of care after 16–20 weeks of gestation.
TRICARE does not cover routine ultrasound screening. Only maternity ultrasound with a valid medical indication that constitutes medical necessity is covered by TRICARE.
Note: For rendering providers billing with a diagnosis of supervision of normal pregnancy,
a secondary diagnosis is required to establish medical necessity of a diagnostic fetal ultrasound performed during a normal pregnancy. Otherwise, the claim will not be reimbursed. Primary prenatal care providers referring patients out to receive an ultrasound must provide the diagnosis (medical indications) to the rendering provider in order to justify medical necessity.
Non-Medically Necessary Maternity Ultrasounds
Ultrasounds that do not have a valid medical indication (e.g., an ultrasound to determine gender) are not covered by TRICARE, and payment may be the beneficiary’s responsibility. If the beneficiary and the rendering ultrasound provider agree to perform an ultrasound that is not considered medically necessary, the ultrasound provider may only bill the beneficiary directly under certain conditions. For more information, see “Hold Harmless Policy” and “Informing Beneficiaries about Non-Covered Services” under “Provider Responsibilities” in the
Important Provider Information section of this handbook.
For more information about maternity care, access Chapter 4, Section 18.1 of the
TRICARE Policy Manual. For updates on ultrasound coverage, refer to the
Notes to Providers Benefit updates page.
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