Fact Sheet: Licensed Midwife Medi-Cal Fee-for-Service Billing Requirements

While Medi-Cal managed care plans (MCP) are required to offer the same benefit package as Medi-Cal Fee-for-Service (FFS) and often utilize Medi-Cal FFS billing codes, some Medi-Cal MCPs may have different utilization management controls and billing policies. As a result, Licensed Midwifes (LMs) should confirm those policies and billing requirements with each Medi-Cal MCP with whom they are contracted to provide services to Medi-Cal members.

LM Enrollment & Eligibility

• LMs must be enrolled through the Department of Health Care Services (DHCS) Provider Enrollment Division using the Provider Application and Validation for Enrollment (PAVE) portal to receive Medi-Cal reimbursement.
• Member eligibility must be verified on the date of service.
• Use the Automated Eligibility Verification System (AEVS) or the DHCS – Provider Portal.
• LMs are eligible to enroll as Comprehensive Perinatal Services Program (CPSP) providers.

Global Obstetrical (OB) Billing Policy

• Global billing includes antepartum and delivery care. It does not include postpartum care.
• The number of reimbursable antepartum visits to bill globally is at least eight (8) and up to (13) during a nine-month period.
  • Note: Additional visits exceeding 13 can be billed outside of the global billing as per visit billing, when a provider documents a second pregnancy within those nine months.
• Global OB codes for LMs include CPT codes 59400, and 59610.
• Claims should include a clinically appropriate ICD-10-CM pregnancy diagnosis code.
• Limitations:
  • Initial OB visit (HCPCS code Z1032) must be separately billed but does not count toward at least eight (8) required visits.
• Some services are permitted outside global OB care including behavioral health, tobacco counseling, IV fluids, fetal non-stress tests (NSTs), neonatal care, limited ultrasounds, contraceptive counseling. 

Per‑Visit OB Billing

• Use per-visit OB billing when fewer than eight (8) antepartum visits occur or when not providing total obstetrical care (which includes all pregnancy-related services from the initial comprehensive prenatal visit through the delivery).
• Use per-visit OB billing or EM codes (99213 or 99214) for all postpartum visits.
• Per‑visit codes include HCPCS codes Z1032, Z1034, and Z1038 and CPT codes 59409 and 59612.
• All claims must follow Claim Submission and Timeliness Overview (claim sub).

Required LM Modifier

• Modifier U9 is required for services performed independently by LMs.
• Incorrect modifier use may lead to claim denials.

Share of Cost Requirements

• Share of Cost (SOC) applies only to the month of delivery.
• Per‑visit SOC must be collected for each month services were rendered.
• Claims may be denied if SOC is unmet or improperly documented.