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TRICARE Policy Manual 6010.63-M, April 2021
Providers
Chapter 11
Section 2.3
Birthing Centers
Issue Date:  May 23, 1988
Revision:  
1.0  ISSUE
Birthing Centers
2.0  DEFINITION
A birthing center is a freestanding or institution-affiliated outpatient maternity care program which principally provides a planned course of outpatient prenatal care and outpatient childbirth service limited to low-risk pregnancies; excludes care for high-risk pregnancies; limits childbirth to the use of natural childbirth procedures; and provides immediate newborn care.
3.0  POLICY
3.1  Certification Requirements
A birthing center which meets the following criteria may be designated as an authorized TRICARE institutional provider:
3.1.1  The predominant type of service and level of care rendered by the center is otherwise covered.
3.1.2  The center is licensed to operate as a birthing center where such license is available, or is specifically licensed as a type of ambulatory health care facility where birthing center specific license is not available, and meets all applicable licensing or certification requirements that are extant in the state, county, municipality, or other political jurisdiction in which the center is located. A freestanding or institutional-affiliated birthing center may be considered for status as an authorized institutional provider.
3.1.3  The center is accredited by a nationally recognized accreditation organization. The following organizations are acknowledged as acceptable accreditation organizations by TRICARE; however, the contractors may contact the Medical Benefits and Reimbursement Section (MB&RS) to determine if other accreditation organizations can be recognized:
3.1.3.1  The Joint Commission, 1 Renaissance Blvd., Oakbrook Terrace, IL 60181, telephone (630) 792-5290.
3.1.3.2  The Accreditation Association for Ambulatory Health Care, Inc., 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091, telephone (847) 853-6060.
3.1.3.3  The Commission for the Accreditation of Birth Centers, P.O. Box 34, East Greenville, PA 18041, telephone (215) 679-4833.
3.1.4  The center has entered into a participation agreement with TRICARE in which the center agrees, in part, to:
3.1.4.1  Participate in TRICARE and accept payment for maternity services based upon the reimbursement methodology for birthing centers;
3.1.4.2  Collect from the beneficiary only those amounts that represent the beneficiary’s liability under the participation agreement and the reimbursement methodology for birthing centers, and the amounts for services and supplies that are not a benefit.
3.1.4.3  Permit access by the Government Designated Authority (GDA), or a designee, to the clinical record of any beneficiary, to the financial and organization records of the center, and to reports of evaluations and inspections conducted by state or private agencies or organizations;
3.1.4.4  Submit claims first to all health benefit and insurance plans primary to TRICARE to which the beneficiary is entitled and to comply with the double coverage provisions;
3.1.4.5  Notify the contractors in writing within three calendar days of the emergency transport of any beneficiary from the center to an acute care hospital or of the death of any beneficiary in the center;
3.1.4.6  A birthing center shall not be a TRICARE authorized institutional provider and benefits shall not be paid for any service provided by a birthing center before the date the participation agreement is signed by the contractor.
3.2  TRICARE Birthing Center Standards
3.2.1  Environment. The center has a safe and sanitary environment, properly constructed, equipped, and maintained to protect health and safety and meets the applicable provisions of the “Life Safety Code” of the National Fire Protection Association.
3.2.2  Policies and procedures. The center has a written administrative, fiscal, personnel and clinical policies and procedures which collectively promote the provision of high-quality maternity care and childbirth services in an orderly, effective, and safe physical and organizational environment.
3.2.3  Informed consent. Each beneficiary admitted to the center will be informed in writing at the time of admission of the nature and scope of the center’s program and of the possible risks associated with maternity care and childbirth in the center.
3.2.4  Beneficiary care. Each woman admitted will be cared for by or under the direct supervision of a specified physician or a specific certified nurse-midwife who is otherwise eligible as an individual professional provider.
3.2.5  Medical direction. The center has written Memoranda Of Understanding (MOU) for routine consultation and emergency care with an obstetrician-gynecologist who is certified or is eligible for certification by the American Board of Obstetrics and Gynecology or the American Osteopathic Board of Obstetrics and Gynecology and with a pediatrician who is certified or eligible for certification by the American Board of Pediatrics or by the American Osteopathic Board of Pediatrics, each of whom have admitting privileges to at least one back-up hospital. In lieu of a required MOU, the center may employ a physician with the required qualification. Each MOU must be renewed annually.
3.2.6  Admission and emergency care criteria and procedures. The center has written clinical criteria and administrative procedures, which are reviewed and approved annually by a physician related to the center for exclusion of a woman with a high-risk pregnancy from center for management of maternal and neonatal emergencies.
3.2.7  Emergency treatment. The center has a written MOU with at least one backup hospital which documents that the hospital will accept and treat any woman or newborn transferred from the center who is in need of emergency obstetrical or neonatal medical care. In lieu of this MOU with a hospital, a birthing center may have an MOU with a physician, who otherwise meets the requirements as an individual professional provider, and who has admitting privileges to a back-up hospital capable of providing care for critical maternal and neonatal patients as demonstrated by a letter from that hospital certifying the scope and expected duration of the admitting privileges granted by the hospital to the physician. The MOU must be renewed annually.
3.2.8  Emergency medical transportation. The center has a written MOU with at least one ambulance service which documents that the ambulance service is routinely staffed by qualified personnel who are capable of the management of critical maternal and neonatal patients during transport and which specifies the estimated transport time to each backup hospital with which the center has arranged for emergency treatment. Each MOU must be reviewed annually.
3.2.9  Professional staff. The center’s professional staff is legally and professionally qualified for the performance of their professional responsibilities.
3.2.10  Medical records. The center maintains full and complete written documentation of the services rendered to each woman admitted and each newborn delivered. A copy of the informed consent document which contains the original signature of the beneficiary, signed and dated at the time of admission, must be maintained in the medical record of each beneficiary.
3.2.11  Quality assurance. The center has an organized program for quality assurance which includes, but is not limited to, written procedures for regularly scheduled evaluation of each type of service provided, of each mother or newborn transferred to a hospital, and of each death within the facility.
3.2.12  Governance and administration. The center has a governing body legally responsible for overall operation and maintenance of the center and a full-time employee who has authority and responsibility for the day-to-day operation of the center.
3.3  Freestanding Ambulatory Surgical Centers (ASCs)
3.3.1  Treatment provided at a freestanding ASC must be prescribed and supervised by a physician.
3.3.2  Childbirth procedures provided by an approved freestanding ASC shall not be covered unless the surgical center is also an authorized birthing center institutional provider.
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