GAP Requests

Keep in mind: these GAP exceptions MUST be requested PRIOR to the delivery date.

In-network exception steps

1. 1

   Call member services on the back of your insurance card.

2. 2

   You will need to listen to the automated system until you get to the authorizations/pre-certification department.

3. 3

   Always try to get to a representative to help you. At this point you already know your benefits and are wanting to start an in-network exception for your midwife and birth center/home birth.

4. 4

   Tell the representative you are calling to start and in-network exception, some insurance companies may call this a waiver or a GAP exception.

5. 5

   Make sure the representative understands this is not an authorization for care. You are requesting to have your provider/home birth/birth center paid at the in-network level based on a network deficiency.

6. 6

   If the representative you are speaking to gives you are hard time and asks why you are requesting an exception when there is an OB/GYN 10-miles from your address, respond with the truth, there are not any in-network providers within a 60-mile radius that offer an out of hospital birth. If there is a nurse midwife within a 60-mile radius they only offer hospital births.

7. 7

   If member services try to dissuade you from setting up the case, ask to speak to their supervisor. It is your right as the member to initiate an in-network exception-The biggest trick in the book is member services stating only the out of network provider can set up the case. It's simply not true.

8. 8

   Be prepared to offer you midwife's name, address, NPI number, Tax ID, and birth center information if you are requesting a birth center birth. Make sure your in-network exception is for the provider AND the birth center if you are wanting a birth center birth.

9. 9

   Insurance will need your diagnosis code, which will always be Z34.90, Z34.93, O80 & Z39.2.

Insurance will also need your CPT codes. Note that it is rare but sometimes insurance will only need the diagnosis code for a waiver and not need the following CPT codes:

For a planned home birth

(if planning a birth center delivery disregard)

Name	CPT Code	Unit/Day
Vaginal Birth	59409	1
Vaginal Delivery & Postpartum Care	59410	1
Aquatherapy	97022	1
Home Visits	99350	15
Labor management at home	G0318	10
GBS	87081	1
Venipuncture	36415	5
Capillary Draw	36416	5
Global PN	59425	4
Global PN	59426	7
PP Visits	59430	6
IV Start	36410	1
IV Therapy	96360	1

For a planned Birth Center Birth

(if planning a home birth disregard)

Name	CPT Code	Units/Days
Vaginal Birth	59409	1
Vaginal Delivery & Postpartum Care	59410	1
Aquatherapy	97022	1
Labor Management at Birth Center	99223	1
Labor Management at Birth Center (subsequent visit)	99233	2
GBS	87081	1
Office Visits	99215	15
Venipuncture	36415	5
Capillary Draw	36416	5
Global PN	59425	4
Global PN	59426	7
PP Visits	59430	6
IV Start	36410	1
IV Therapy	96360	1

Prenatal and postpartum care only

If your policy covers prenatal and postpartum care (your home birth is excluded from coverage) please only request the following CPT codes with the location being the provider's office:

Diagnosis Code Z34.90 & Z39.2

Name	CPT Code	Days/Units
Global PN	59425	6
Global PN	59426	20
PP Visits	59430	4

For Planned Hospital Deliveries

Diagnosis Codes Z34.90, Z34.93, O80, Z39.2

Name	CPT Code	Units/Days
Virginal Birth	59409	1
Hydrotherapy	97022	1
Labor Management at Hospital	99233	1
Labor Management at Hospital	99234	1
Postpartum Care	59430	6
Venipuncture	36415	5
Capillary Draw	36416	5
Antepartum Care	59426	7
Office Visit	99215	15
GBS	87081	1

Questions? Email me at maggie@napiermidwiferybilling.com