Mga Madalas Itanong sa Serbisyo ng Doula
Mga Tagapagbigay ng Doula – Mga Plano ng Pinamamahalaang Pangangalaga
Pangkalahatang-ideya
Effective January 1, 2023, the Department of Health Care Services (DHCS) added doula services as a benefit with the goal of preventing perinatal complications and improving health outcomes for birthing parents and infants.
Per State Plan Amendment (SPA) 22-0002, doula services are provided as preventive services pursuant to Title 42 Code of Federal Regulations (CFR) Section 440.130(c) and must be recommended by a physician or other licensed practitioner of the healing arts within their scope of practice under state law.
DHCS covers doula services in managed care delivery systems for pregnant and postpartum Medi-Cal Members (Members). Services include non-medical support for prenatal and postpartum visits, and during labor and delivery, miscarriage, and abortion.
Enrollment and Credentialing Requirements
1. What is the process to become a Medi-Cal Doula Provider?
Doulas may apply for enrollment through the DHCS PAVE – Provider Application and Validation for Enrollment portal. Supporting videos and additional information on how to apply can be found in the “Doula Application Information” webpage. Doulas can also reference the Medi-Cal Doula Provider Enrollment Checklist to identify what documents they need before they begin their application.
Please note, Doulas will need to register for a National Provider Identifier (NPI) to enroll with DHCS. An NPI is a numeric identifier assigned to a health care Provider by the Centers for Medicare & Medicaid Services (CMS). Doulas can apply for an NPI online or by mail through the CMS NPI Application/Update Form webpage.
Doulas will also need to contract separately with each individual Medi-Cal managed care plan (MCP) operating within their service area to provide covered services to Members who receive Medi-Cal through the managed care delivery system. Doulas must enter into contracts with MCPs to receive reimbursement for services provided to Members.
Additional information on enrolling as a Medi-Cal Doula Provider can be found in DHCS’ Doula Services Frequently Asked Questions -Enrolling as a Doula.
2. How do I find MCPs in my county?
To find MCP(s) in your county, please visit DHCS’ Medi-Cal Managed Care Health Plan Directory
If you are unsuccessful in contacting MCP(s) in your county, you may reach out to DHCS for further assistance via email at DoulaBenefit@dhcs.ca.gov.
3. Why do some MCPs have additional requirements after I have enrolled in Medi-Cal with DHCS?
Enrollment, MCP credentialing, and MCP contracting processes are separate and distinct. Each process has its own requirements as required by various state and federal laws and DHCS policy. Each process is described below:
- Enrollment: Providers that have a state-level fee-for-service (FFS) enrollment pathway must enroll in the Medi-Cal program if they wish to provide services to Members. A Provider has the option to enroll through the MCP or through DHCS.
- Credentialing: The process of determining a Provider or an entity’s professional or technical competence, and may include providing documentation, as applicable, of registration, certification, licensure, and professional association membership.
- Contracting: The written agreement between a Provider and a MCP.
4. Why do MCPs have to credential and re-credential Doulas?
Doulas enrolled in Medi-Cal also need to be credentialed by MCPs. MCPs are required to credential all contracted Network Providers that render services to Members, in accordance with state and federal law. Further, DHCS requires each MCP to verify every three years that each Network Provider delivering services continues to possess valid credentials.
You may direct questions pertaining to credentialing and re-credentialing requirements to the MCP.
5. As part of credentialing for Doulas, do MCPs need to review or validate documents already submitted to DHCS via PAVE?
Some screening and enrollment requirements may overlap with credentialing and re-credentialing requirements. Any such overlap does not require MCPs to duplicate any of the activities described in APL 22-013.
MCPs may review requirements and documents that DHCS verified during a Doula’s PAVE application and enrollment process. Specifically, PAVE requires Doulas to submit proof of CPR certification from American Red Cross or American Heart Association, attestation to completion of basic HIPAA training, and either a certificate of completion that meets requirements or attestation of experience and three testimonial letters.
If a MCP relies on the screening and enrollment activities conducted by DHCS, the MCP must comply with all credentialing and re-credentialing requirements.
6. Can MCPs have a single contract for Medi-Cal and commercial lines of business?
DHCS does not prescribe any particular contracting type between MCPs and Doulas. MCPs are encouraged to be flexible when contracting with Doulas as long as it incorporates DHCS policy on the doula services benefit. MCPs that have single contract agreements/templates for Medi-Cal and commercial lines of business should denote the difference via exhibits that meet state, federal and contractual requirements.
You may direct questions pertaining to contracting arrangements to the MCP.
7. Are Doulas required to have their own insurance?
DHCS does not impose any insurance requirements on Doulas as part of their Medi-Cal enrollment and does not require MCPs to do so. However, MCPs may elect to impose insurance requirements for Doulas. The requirements should be reasonable and align with the non-clinical nature and scope of practice of Doulas. DHCS released information regarding insurance in its Medi-Cal Doula Services Best Practices document, which advises MCPs should consider the following best practices:
Relative to insurance requirements, ensure they align with Doula Providers’ non-licensed, non-clinical role, as follows:
- Professional Liability coverage, if a MCP elects to impose this as a requirement, should be no more than $1 million per incident/$3 million aggregate.
- Workers’ Compensation may only be required when the Doula operates as an employer (e.g., hires staff or contracts as a Doula group).
- Avoid imposing malpractice or other insurance requirements (such as umbrella insurance, cyber liability insurance, sexual misconduct and molestation liability insurance, etc.) that may be a MCP requirement for licensed Providers rendering clinical care since it is inconsistent with Doula Providers’ scope of practice as a non-licensed, non-clinical professionals.
You may direct questions pertaining to insurance requirements to the MCP.
8. Why are MCPs not accepting my application to contract as a Doula in their Network?
DHCS cannot prescribe any particular contracting type between MCPs and Doulas. MCPs generally have the discretion to contract or not contract with any Medi Cal eligible or enrolled Provider. MCPs may execute a Letter of Agreement (LOA), which serves as a written arrangement between the MCP and an out-of-network Doula.
If a Member needs to be paired with a Doula, please have the Member reach out to their MCP.
9. How long does it take for MCPs to determine an application to contract as a Doula in their network?
MCP must complete the process and provide the applicant with a written determination on MCP letterhead within 120 calendar days of its receipt of a Provider application. A MCP may allow a Provider to participate in its Network for up to 120 calendar days, pending the outcome of the screening process, in accordance with APL 22-013.
10. Who can I contact if MCPs are not responsive to my inquiries?
If you have reached out to the MCP(s) and continue to have challenges, please email DHCS at DoulaBenefit@dhcs.ca.gov and provide the following information. Do not mention any Member by name or include any protected health information in your email.
- Pangalan ng Doula
- Doula NPI
- What counties does the Doula provide services?
- What MCP(s) does the Doula have contract(s) with?
- Name of the MCP(s) that have not been responsive
- Name of any MCP representatives that you have spoken to regarding the issue. Please include the email or phone number used to contact MCP.
- Maikling paglalarawan ng isyu
- (mga) petsang nauugnay sa isyu
- Impormasyon sa pakikipag-ugnayan para sa follow-up (email at telepono ang ginustong)
Kasapatan ng Network
11. Is there a standard for the number of doulas with whom a MCP needs to contract with to maintain network sufficiency?
As part of their network, MCPs must ensure and monitor sufficient Provider networks within their service areas, including Doulas. To support a sufficient doula network, MCPs must make contracting available to both individual Doulas and Doula groups. However, MCPs generally have the discretion to contract or not contract with any Medi-Cal eligible or enrolled Provider.
MCPs must work with their in-Network hospitals/birthing centers to ensure there are no barriers to accessing Doulas when accompanying Members for prenatal visits, labor and delivery support, and postpartum visits regardless of outcome (stillbirth, abortion, miscarriage, live birth).
MCPs must coordinate for out-of-network access to doula services for their Members if an in-Network Doula Provider is not available.
Hospital Settings
12. Do hospitals have to have written P&Ps that include information regarding patient visitation rights, including for support persons?
Yes. Under applicable state and federal requirements, all hospitals must have written P&Ps regarding patient visitation rights. Some hospitals may specifically reference “Doulas” while others may refer to a “support person” generally. Federal and state law allows hospitals to restrict visitation for various reasons. Examples of permission restrictions and/or reasons are found in the CMS Hospital Interpretive Guidelines and CMS Critical Access Hospital Interpretive Guidelines.
The Hospital P&Ps must address inpatient and outpatient settings and include any clinically necessary or reasonable restrictions on visitation and the reasons for those restrictions. Additionally, all hospitals must inform patients in writing of their right to have visitors of their choosing. These requirements are outlined in Title 42 CFR Section 482.13(h), which includes hospitals that receive federal Medicaid dollars, as follows:
(h) A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. A hospital must meet the following requirements:
(1) Inform each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights under this section.
(2) Inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.
(3) Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.
(4) Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences.”
13. Where can I learn more about a hospital’s P&Ps?
Bawat ospital ay may kanya-kanyang P&P, at walang dalawa ang magkapareho. Samakatuwid, makabubuting magtanong tungkol sa mga P&P ng isang partikular na ospital sa pamamagitan ng pagbisita sa website ng ospital o sa pamamagitan ng direktang pakikipag-ugnayan sa ospital.
14. What are MCPs’ expectations for Doulas in the hospital setting?
A subset of MCPs issued a Doula Guidance for Hospitals which advises hospitals on the roles of Doulas and how they should be recognized in the hospital setting.
15. What can be done if Doulas experience difficulty with, or is denied access to, providing support to Members in a hospital?
Doulas are encouraged to reach out to the Member’s MCP and report such occurrences, following their established compliant processes.
If the issue(s) remain unresolved, Doulas can reach out to DHCS at DoulaBenefit@dhcs.ca.gov and provide the following information. Do not mention any Member by name or include any protected health information in your email.
- Doula Name;
- Doula NPI;
- MCP Name;
- Name of any MCP representative(s) that you spoke to regarding the issue;
- Pangalan ng ospital;
- Pangalan ng sinumang kinatawan ng ospital na nakausap mo tungkol sa isyu;
- Maikling paglalarawan ng isyu;
- (mga) petsa na nauugnay sa isyu; at
- Impormasyon sa pakikipag-ugnayan para sa follow-up (email at telepono ang ginustong).
DHCS can and does work closely with the California Hospital Association (CHA), other hospital associations, and individual hospitals, to address these types of concerns, and work to resolve the individual’s circumstance.
Additionally, DHCS can provide technical assistance directly to hospitals to clarify that doula services are a covered Medi-Cal benefit and that Members have a right to visitors/support persons of their choosing, which includes Doulas.
16. What can be done if Members experience difficulty with, or is denied access to, Doula providing support in a hospital?
Members are encouraged to reach out to their MCP and report such occurrences. Members can file a complaint or ask for help by mail, online, or phone about their benefits, doctors, and how to use their health coverage.
Members can find additional information regarding the complaint process in their Member Handbook/Evidence of Coverage or visit DHCS’ File a Complaint webpage.
Billing and Payment
17. How will Doulas receive payments from MCPs for services provided to their Members?
Doulas who provide services to Members must enter into contracts with MCPs to receive reimbursement for services provided. Doulas must follow the claims and reimbursement processes for the MCPs with whom they are contracted.
18. What are the billable codes for doula services?
The billing codes are listed in the Medi-Cal Provider Manual: Doula Services.
19. How much does Medi-Cal pay Doulas for their services?
For current Medi-Cal rates, providers are encouraged to use the Medi-Cal Provider Manual Doula Services (doula) to locate applicable CPT and/or HCPCS codes for billing doula services. Those applicable codes can be used to look up the current fee-for-service rates on the Medi-Cal Rates | Medi-Cal Providers webpage. MCPs must ensure that eligible Doulas receive no less than the applicable minimum fee schedule rates for qualifying services under 2024 Targeted Provider Rate Increase (TRI). Please see the Doula Rates Chart for a comparison of the 2023 rates to the 2024 rates.
MCPs only pay the TRI to eligible Doulas with whom they have a contract or an unbroken chain of contracts between the Doula and the MCP. MCPs are not required to pay the TRI to Doulas when they are working under Letter of Agreement or a one-time agreement.
Doulas and MCPs may negotiate for a higher rate, but MCPs are not obligated to pay anything higher than what is listed in the TRI Fee Schedule or what is listed as Medi-Cal Rates.
20. How will Doulas receive payment from MCPs for services provided to their members?
Doulas who provide services to Members must enter into contracts with MCPs to receive reimbursement. Doulas must follow the claims and reimbursement processes for the MCPs with whom they are contracted.
21. Will MCPs provide claiming, billing, or invoice training to their contracted Doulas?
MCPs must provide direct instruction, training, and technical assistance to its Providers to support information transmission and the submission of Clean Claims, including bills or invoices submitted by Doulas that are unable to submit claims through an electronic file format.
Doulas should contact the MCPs that are contracted with for specific claims, billings, or invoice training.
22. When can I expect payment from a MCP after submitting a claim?
MCPs are expected to pay clean claims within 30 calendar days of receipt, unless the Provider and MCP have agreed in writing to an alternate payment schedule.
A clean claim has all the required information needed for the MCP to process the Provider’s payment. For example, a clean claim is a claim that does not need to be returned to the Provider for corrections or additional information in order to be paid.
If the MCP does not pay a clean claim within 45 Working Days of receipt, it will owe the Provider interest at the rate of 15 percent per annum beginning on the first day after a 45 working day period.
Additional information regarding requirement of timely payment of claims can be found in APL 23-020.
23. MCPs are taking a long time to reimburse for submitted claims. How can I get assistance regarding claims submission and billing?
MCPs must have processes in place to identify, triage, and resolve Provider concerns that do not rise to the level of a formal provider dispute, which include but is not limited to: clear points of contact for Provider inquiries and concerns; and ongoing education for Providers on claims payment adjudication protocols to prevent payment delays.
Doulas can submit a provider dispute resolution to the MCP if they submitted a clean claim that was not paid within 30 days of claim submission or does not receive a response within 30 days of submitting the claim. Both contracted and non-contracted Providers can submit disputes directly to MCPs to obtain resolution.
Information regarding MCP provider dispute resolution mechanism can be found in DHCS’ APL 26-017, Provider Dispute Resolutions with Managed Care Plans Provider Bulletin, and the Medi-Cal FFS and MCP Provider Compliant Pathways.
24. What can I do if a MCP denied my clean claim?
If claims are denied, rejected, or contested in whole or in part, the MCP must specify the reason(s) for contesting or denying a claim and specify the additional information necessary to complete the claim as well as offering technical assistance to remediate deficiencies.
Doulas can submit a provider dispute resolution to the MCP If they submitted a clean claim and receive a denial they wish to dispute. Both contracted and non-contracted Providers can submit disputes directly to MCPs to obtain resolution.
Information regarding MCP provider dispute resolution mechanism can be found in DHCS’ APL 26-017, Provider Dispute Resolutions with Managed Care Plans Provider Bulletin, and the Medi-Cal FFS and MCP Provider Compliant Pathways.
Provider Dispute Resolution Process with MCP
25. How can I initiate a provider dispute resolution process with a MCP?
MCPs must have a fast, fair, and cost-effective Provider Dispute Resolution Mechanism in place for Providers to submit disputes.
Doulas who are contracted with MCPs will have the provider dispute resolution process detailed in their contracts, in the MCP’s provider manual, and/or on the MCP’s website. Many MCPs also accept claims disputes through their provider portals. Contact your MCP if you are unable to locate information on the MCP’s provider dispute resolution submission process.
If the claims were rejected due to insufficient information or other issues, those issues must be resolved, and a clean claim must be submitted prior to the provider dispute resolution.
Information regarding MCP Provider Dispute Resolution Mechanism can be found in DHCS’ APL 26-017, Provider Dispute Resolutions with Managed Care Plans Provider Bulletin, and the Medi-Cal FFS and MCP Provider Compliant Pathways.
If you are facing challenges with initiating a provider dispute with a MCP, you may reach out to DHCS for further assistance via email at: DoulaBenefit@dhcs.ca.gov.
26. What can I do if I completed the MCP provider dispute resolution process and my issue is still unresolved?
If you have completed the MCP provider dispute resolution process and received an unsatisfactory response, you may file a complaint directly with the Department of Managed Health Care (DMHC) through the Provider Complaint Against a Plan web page.
- File a complaint directly to DMHC at: How to File a Complaint
- For questions email: providercomplaintunit@dmhc.ca.gov
- Complaint line toll-free at (877) 525-1295.
- Other Resource: Frequently Asked Questions and View All Health Plans.
If you are unsatisfied with the resolution provided from the steps above, you may contact DHCS at medi-cal.benefit@dhcs.a.gov.
Information regarding MCP provider dispute resolution mechanism can be found in DHCS’ APL 26-017, Provider Dispute Resolutions with Managed Care Plans Provider Bulletin, and the Medi-Cal FFS and MCP Provider Compliant Pathways.
Mga mapagkukunan
27. Where can I find more information on the DHCS doula services benefit?
- Doula Services as a Medi-Cal Benefit: https://www.dhcs.ca.gov/provgovpart/Pages/Doula-Services.aspx
- Doula Providers: https://www.dhcs.ca.gov/Providers-partners/Doula-Providers/
- Doula Services for Medi-Cal Members: https://www.dhcs.ca.gov/Providers-partners/Doula-services-for-medi-cal-members
28. Where can I find information on DHCS’ guidance and recommendations to MCPs regarding the doula services benefit?
- APL 23-024. DHCS is revising the APL. Please see the table below for the proposed APL revisions.
| Proposed revisions to APL |
| Documentation Requirements: Clarifies guidelines on MCPs documentation requirements as outlined in the Medi-Cal Provider Manual. |
| Insurance Requirements: Provide guidance on insurance requirements |
| Letter of Agreements: Provide guidance on a member’s request for an OON Doula Provider |
- Medi-Cal Doula Services Best Practices. DHCS prepared Medi-Cal Doula Services: Best Practices Guide to make recommendations as to best practices that may be operationalized to support access and reduce barriers to doula services for Members across both the Medi-Cal fee-for-service and Medi-Cal managed care delivery systems.