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Maternity care includes medical services related to prenatal care, labor and delivery, and postpartum care. TRICARE-eligible women 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 prior authorization from Humana Military for TRICARE Prime, TPR, and TPRADFM beneficiaries. Obtain prior authorization from Humana Military at the mother’s first pregnancy-related appointment with the PCM or provider. The prior authorization begins with the first prenatal visit and remains valid until 42 days after birth. Both inpatient and outpatient services require prior authorization.
If your patient intends to deliver in a civilian (non-MTF) facility or birthing center, you must obtain a separate prior authorization at the time of delivery. If the patient is a TRICARE Prime enrollee, she must use a network facility for delivery. Maternity inpatient stays require additional prior authorization. Length of stay cannot be restricted to less than 48 hours following a normal vaginal delivery or 96 hours following a cesarean section.
Covered services include:
- Obstetric visits throughout the pregnancy
- Medically necessary fetal ultrasounds
- Hospitalization for labor, delivery, and postpartum care
- Anesthesia for pain management during labor and delivery
- Medically necessary cesarean sections
- Management of high-risk or complicated pregnancies
The following services are not covered:
- Fetal ultrasounds that are not medically necessary (e.g., to determine the baby’s sex), including three- and four-dimensional ultrasounds
- Services and supplies related to noncoital reproductive procedures (e.g., artificial insemination)
- Management of uterine contractions with drugs that are not U.S. Food and Drug Administration-approved for that use (i.e., off-label use)
- Home uterine-activity monitoring and related services
- Unproven procedures (e.g., lymphocyte or paternal leukocyte immunotherapy to treat recurring miscarriages, salivary estriol test for preterm labor)
- Umbilical cord blood collection and storage, except when stem cells are collected for subsequent use in the treatment of tumor, blood, or lymphoid disease
- Private hospital rooms
Maternity Ultrasounds
TRICARE covers professional and technical components of medically necessary fetal ultrasounds as well as the maternity global fee. TRICARE covers medically necessary maternity ultrasounds that may be needed to:
- Estimate gestational age due to unknown date of last menstrual period, irregular periods, size/date different by greater than two weeks, or pregnancy while on oral contraceptive pills Note: Estimated gestational age confirmation is not a medically necessary indication.
- Evaluate fetal growth when the fundal height growth is significantly greater than expected (more than 1 cm per week) or less than expected (less than 1 cm per week)
- Conduct a biophysical evaluation for fetal well-being when the mother has certain conditions (e.g., insulin-dependent diabetes mellitus, hypertension, systemic lupus, congenital heart disease, renal disease, hyperthyroidism, prior pregnancy with unexplained fetal demise, multiple gestations, post-term pregnancy after 41 weeks, intrauterine growth retardation, oligohydramnios or polyhydramnios, preeclampsia, decreased fetal movement, isoimmunization)
- Evaluate a suspected ectopic pregnancy
- Determine the cause of vaginal bleeding
- Diagnose or evaluate multiple births
- Confirm cardiac activity (e.g., when heart rate is not detectable by Doppler and/or suspected fetal demise)
- Evaluate maternal pelvic masses or uterine abnormalities
- Evaluate suspected hydatidiform mole
- Evaluate the condition of the fetus in late registrants for prenatal care
Note: You must issue a secondary diagnosis to establish medical necessity for an ultrasound performed under a diagnosis of supervision of normal pregnancy. Otherwise, TRICARE will not reimburse the claim. A primary prenatal care provider who refers a patient to another provider for an ultrasound must provide the diagnosis (medical indication) to the rendering provider to justify medical necessity.
Per American College of Obstetricians and Gynecologists guidelines, an ultrasonography should be performed only when there is a valid medical indication. A physician is not obligated to perform an ultrasonography for a low-risk patient with no medical indications.
Some providers offer routine ultrasound screening as part of the scope of care after 16–20 weeks of gestation. TRICARE does not cover routine ultrasound screening. TRICARE only covers maternity ultrasounds with valid medical indications that constitute medical necessity. If the beneficiary and provider agree to perform an ultrasound that is not considered medically necessary, the provider may only directly bill the beneficiary under certain conditions. For more information, see “Informing Beneficiaries about Non-Covered Services” under “Provider Responsibilities” in the Important Provider Information section of this handbook. Back to Top |
