Table of Contents

1. Medi‑Cal Doula Benefit: What You Need Before Filing
2. Key Medi‑Cal Codes, Rates & Diagnosis Requirements
3. Enrolling as a Medi‑Cal Doula Provider
4. Field‑by‑Field Walkthrough of the CMS‑1500 for Medi‑Cal Doulas
5. How to Submit the Claim: Fee‑for‑Service vs Managed Care Plans
6. Common Mistakes & Tips for Faster Payment
7. FAQs
8. Resources

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Medi‑Cal Doula Benefit: What You Need Before Filing

• Doula services became a covered benefit in California Medi‑Cal on January 1, 2023, available under both fee‑for‑service (FFS) and managed care delivery systems.
• The services covered include non‑medical support during prenatal and postpartum visits; support during labor, birth, miscarriage, and abortion. Also support up to one year postpartum.
• A written recommendation from a physician or other licensed practitioner is required, but Medi‑Cal has issued a standing recommendation for the “initial set” of doula services for any pregnant member or someone postpartum up to one year. Extra visits beyond the standing recommendation require another recommendation.
• You’ll need to verify member eligibility for the month of service. If the member is under a managed care plan (MCP), make sure the doula is contracted with that MCP or that there is a valid pathway for reimbursement via the MCP.

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Key Medi‑Cal Codes & Diagnosis Requirements

• Medi‑Cal FFS rates for doula services were increased as of January 1, 2024, under the Targeted Provider Rate Increase (TRI). The rates are set at 87.5% of the lowest statewide Medicare rate for comparable maternal services.
• Medi‑Cal requires the use of modifier XP when billing doula services to indicate that the service was performed by a doula (non‑licensed provider).
• As of November 1, 2024, Medi‑Cal requires diagnosis codes on all doula service claims in order to be paid. Since doulas are not diagnosing in the medical sense, DHCS has identified a set of general ICD‑10 diagnosis codes that doulas may use. The diagnosis codes should be entered without the decimal point when on the CMS‑1500 form.
  • Z32.2 – Encounter for childbirth instruction
  • Z32.3 – Encounter for childcare instruction
  • Z33.1 – Pregnant state, incidental
  • Z39.0 – Encounter for care and examination of mother immediately after delivery
  • Z39.1 – Encounter for care and examination of lactating mother
  • Z39.2 – Encounter for routine postpartum follow-up
• Perinatal visits can be billed under one of the following codes:
  • Z1032 – Extended initial visit 90 minutes
  • Z1034 – Prenatal visit
  • Z1038 – Postpartum visit
  • T1032 – Extended postpartum doula support, per 15 minutes
• Delivery support can be billed under one of the following codes:
  • 59409 – Doula support during vaginal delivery only
  • 59612 – Doula support during vaginal delivery after previous caesarean section
  • 59620 – Doula support during caesarean section
• Abortion or miscarriage support can be billed under one of the following codes:
  • T1033 – Doula support during or after miscarriage
  • 59840 – Doula support during or after abortion

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Enrolling as a Medi‑Cal Doula Provider

If you want to serve members in managed care plans, you must be enrolled as a Medi-Cal doula, and also contract with those MCPs. See our other blog post for more information about enrolling. Without a contract, you may not be reimbursed or may get paid at lower rates or old rates.

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Field‑by‑Field Walkthrough of the CMS‑1500 for Medi‑Cal Doulas

Here’s how doulas in California should complete key CMS‑1500 fields for Medi‑Cal claims. Always check payer instructions but these are the standard fill‑ins.

• Item 1 / 1a: mark the type of insurance (e.g. Medicaid / Medi‑Cal), and enter the insured’s ID number exactly as it appears on their insurance card.
• Item 2: Patient’s name (the member receiving doula services), last name, first name, middle initial.
• Item 3: Patient’s date of birth (MM‑DD‑YYYY) and sex ("M" or "F").
• Item 4: If insured (policyholder) is not the member, put their name; if same, use the patient name or as per payer instruction.
• Item 5: Patient’s address and phone (full mailing address, city, state, ZIP).
• Item 6: Relationship of patient to insured (likely “Self” if the member is insured).
• Item 7: Insured’s address if different.
• Item 9 / 9a / 9d: If there is another health benefit plan (secondary insurance), include name, policy #, etc. Leave blank if none.
• Item 11 / 11a / 11b / 11c / 11d: Enter policy or group number, insured’s date of birth and sex (if insured is not the patient), name of plan, and indicate whether there is another health benefit plan.
• Item 21: Put the appropriate Medi‑Cal approved ICD‑10 diagnosis code(s) that are valid for doula services. Use the general codes DHCS has made available. Do not use a decimal point (e.g. “Z322” instead of “Z32.2”) if that’s required by your claim form.
• Item 22: Only fill this if you are resubmitting or correcting a prior claim.
• Items 24A‑24G (service lines):
  • 24A – date(s) when the doula service was provided
  • 24B – place of service code (home, hospital, office, etc.). Use correct POS code Medi‑Cal requires.
  • 24D – list the procedure or service code (CPT/HCPCS) that Medi‑Cal recognizes for that type of doula service + the XP modifier.
  • 24E – diagnosis pointer(s) linking to the diagnosis code in item 21.
  • 24F – charge for each service line (use the Medi‑Cal rate allowed).
  • 24G – units or number of hours/units as appropriate.
• Item 25: Provider’s federal tax ID or SSN depending on your business setup.
• Item 26: Your internal patient account number (optional but helpful).
• Item 27: Accept assignment? If Medi‑Cal allows or requires this, mark “Yes” if you accept the rate assigned by Medi‑Cal.
• Item 28: Total charge for all lines combined.
• Item 29: Amount paid by another health plan if secondary insurance paid something.
• Item 30: Balance due from Medi‑Cal (what you are asking them to pay).
• Item 31: Signature of provider (or authorized representative) and date. Medi‑Cal may accept “Signature on File” in some situations, check your provider manual.
• Item 32: Print provider’s name and credentials (e.g. “Doula”) and NPI.
• Item 33: Provider’s business address, phone number, NPI, and referring provider info if required. Use your physical address (not PO box) where asked, especially for enrollment/address fields.

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How to Submit the Claim: Fee‑for‑Service vs Managed Care Plans (MCPs)

• For fee‑for‑service Medi‑Cal:
  • Once enrolled and certified, you bill Medi‑Cal directly using the CMS‑1500 form.
  • You need to follow Medi‑Cal’s provider manual for doula services.
  • Make sure your claim is clean: correct IDs, diagnosis codes, modifiers, POS, signature.
  • Timely filing limits apply. Claims submitted past those deadlines may be denied.
• For Medi‑Cal Managed Care Plan (MCP) members:
  • You need a contract with the specific MCP to reimburse for services provided to their members.
  • You follow the MCP’s own claims submission process (they may accept CMS‑1500, or web/electronic systems, or provider portals).
  • You still must adhere to Medi‑Cal rules for doula services (rate, diagnosis, modifier XP, recommendation, etc.).
  • You can get help: MCPs are required by DHCS to provide training/technical assistance for doulas on billing and submitting “clean claims.”

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Common Mistakes & Tips for Faster Payment (Medi‑Cal Doula Specific)

• Not using the XP modifier – leaves payer unaware that a doula (non‑licensed) provided the service; can result in denial or wrong rate.
• Missing or invalid diagnosis code after Nov 1, 2024 – required by Medi‑Cal; omitting it will likely cause claim to be rejected.
• Using wrong place of service code – if the service took place at home, hospital, etc., using the wrong POS may cause denial or reduced reimbursement.
• Not having a valid recommendation on file for additional postpartum visits. Without it, claims may not process.
• Billing without being properly enrolled or contracted – if you are not enrolled through PAVE and/or contracted with the MCP (if applicable), Medi‑Cal or the MCP may refuse reimbursement or pay old rates.
• Illegible or incorrect entries on the CMS‑1500 (dates, names, ID numbers, NPI) – use clear printing or typed entries; double check IDs and spelling.
• Submitting claims late or not following up on denials / rejections – know the timely filing deadlines; and use the provider dispute resolution process if needed. MCPs must pay “clean claims” in specified timeframes per All Plan Letter 23‑020.

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FAQs (Medi‑Cal Doula Billing)

Do I have to enter a diagnosis code for every doula service claim?

Yes. As of November 1, 2024, Medi‑Cal requires a diagnosis code on all claims for doula services. DHCS has published lists of general ICD‑10 codes doulas may use.

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What billing / procedure codes do I use?

Use the codes listed in the Medi‑Cal Provider Manual: Doula Services. Include the XP modifier. The codes are the same as those used for licensed maternal health providers (for many services) when billing the Medi‑Cal FFS system.

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Can I get paid for managed care plan (MCP) members?

Yes, but you must have a contract with the MCP. Follow the MCP’s claims process, while still using Medi‑Cal’s rules (recommendation, diagnosis code, XP modifier, etc.).

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How many prenatal or postpartum visits are allowed?

Under Medi‑Cal: one initial visit, up to eight additional visits in any combination of prenatal and postpartum via the standing recommendation. Up to two extended three‑hour postpartum visits. For more postpartum visits beyond that, a second recommendation is needed.

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What are the rates Medi‑Cal pays doulas now?

After TRI effective Jan 1, 2024: about $197.98 for initial 90‑minute visit; ~$162.11 for prenatal or postpartum visit; extended postpartum support ~$486.36; other rates higher for delivery support, caesarean etc.

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What happens if my claim is denied or I’m paid at the wrong rate?

Check the denial reason. Ensure your claim had all required elements: provider enrollment, valid recommendation, diagnosis code, XP modifier, correct CPT/HCPCS codes, POS, etc. If necessary, enter the provider dispute process with the MCP or DHCS. Keep documentation. MCPs must respond to “clean claims” in timelines set by DHCS.

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Conclusion

Given the complexity of enrolling, coding, documenting, and submitting claims for Medi-Cal doula services, especially with evolving requirements like diagnosis codes and modifier use, it's clear that billing isn't just a side task; it's a specialized job. Mistakes can delay or prevent payment, and navigating both fee-for-service and managed care systems can be overwhelming. That’s where Loula comes in. Our team understands the unique needs of doulas and the ins and outs of Medi-Cal, ensuring your claims are submitted correctly and on time, so you can focus on care, not paperwork.

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