Obstetric Care

Updated: October 2026

Purpose

Comprehensive prenatal, intrapartum, and postpartum care for pregnant members improves health outcomes for our youngest members and their families. Maternal health services begin at the first prenatal appointment and continue for twelve months following delivery. 

Applicability

Eligible Providers

To receive payment from ND Medicaid, the eligible servicing and billing providers must be enrolled with ND Medicaid on the date of service, and their National Provider Identifiers (NPIs) must be active in their Medicaid enrollment records. Servicing providers acting as a locum tenens provider must be enrolled with ND Medicaid, and services they provide must be billed with their NPI. Please refer to provider enrollment for additional details on enrollment eligibility and supporting documentation requirements.

Obstetric care services can be provided by the following enrolled providers as allowed by their scope of licensure: 

  • Physician 
  • Physician Assistant 
  • Certified Nurse Practitioner 
  • Certified Nurse Midwife

ND Medicaid does not cover home births or births not attended by a physician or certified nurse midwife.

Eligible Members

Providers are responsible for verifying a member’s eligibility before providing services. Eligibility can be verified using the ND Medicaid MMIS Portal or through the Automated Voice Response System by dialing 1.877.328.7098.

Obstetric care services are available to members who are in the antepartum, delivery and postpartum period of a pregnancy. 

Refer to the Member Eligibility Manual for additional information regarding eligibility including information regarding limited coverage categories. 

Covered Services and Limits

General Provider Policies

The General Provider Policies details basic coverage requirements for all services. Basic coverage requirements include:

  • The provider must be enrolled in ND Medicaid;
  • Services must be medically necessary;
  • The member must be eligible on the date of service; and
  • If applicable, the service has an approved service authorization. 

The Procedure Code Look-up Tool can be used to identify if a procedure code is covered by ND Medicaid, along with code-specific details such as ORP requirements, Service Authorization requirements, and current rates. 

Prenatal Care

  • Routine prenatal visits including: 
    • Monthly visits up to 28 weeks gestation;
    • Bimonthly visits until 36 weeks; and
    • Weekly visits until delivery.
  • Routine history;
  • Physical exam;
  • Recording of weight; 
  • Blood pressure; 
  • Fetal heart tones; and
  • Routine chemical urinalysis (CPT® code 81000 and 81002).
 
Initial Visit 

The initial visit must include the date of service and proper documentation along with the following: 

  • Comprehensive history and physical exam;
  • Immunizations as appropriate and/or documentation of any refusals;
  • Perform initial labs as indicated, which may include, Syphilis, STIs, HIV and Hepatitis C testing;
  • Risk assessment and referral to services as appropriate. Services may include:
    • Mental health; 
    • Substance abuse; and
    • Social determinants of health (housing, food, service agencies, etc.).

Delivery 

  • Admission to the hospital, including history and physical;
  • Management of uncomplicated labor; 
  • Vaginal or cesarean delivery of singleton (see billing for multiple births below);
  • Delivery of placenta;
  • Administration of intravenous oxytocin;
  • Insertion of cervical dilator; 
  • Repair of first- or second-degree laceration; 
  • Simple removal of cerclage;
  • Uncomplicated inpatient visits immediately following delivery; and 
  • Education services such as breastfeeding, lactation, and basic newborn care. 

Delivery begins on the date of hospitalization for delivery and extends through the date of discharge. 

A Long-acting reversible contraceptive (LARC) device will be reimbursed outside of a Diagnosis Related group (DRG) payment to the in-state prospective payment system (PPS) hospital when the device is inserted prior to the discharge from the delivery stay. 

Billing Instructions: 

  • The hospital must bill the LARC device on an Outpatient claim with type of bill 0131;
  • Report revenue code 0636 with one of the following J codes and the appropriate NDC: 
    • J7296
    • J7297
    • J7298
    • J7300
    • J7301
    • J7307
  • The date of service on the claim will be the date the device was placed; 
  • Payment for the device will be based on the fee schedule; 
  • The facility charges related to the insertion of the device are part of the DRG 
  • payment; and 
  • Do not include the charges for the LARC device that is billed on the Outpatient claim on the Inpatient claim.
 
Postpartum
  • Routine outpatient postpartum visit(s); and
  • Mental health screening. 

The postpartum period begins after the member is discharged from the hospital and extends for a period of 6 weeks following delivery.

Genetic Screenings 

ND Medicaid covers the following genetic screening tests when medically necessary:

  • Noninvasive prenatal testing/screening (NIPT/S) (81420).

Prior authorization is needed for:       

  • Fetal chromosomal microdeletion(s) genomic sequence analysis (e.g.,DiGeorge syndrome, Cri-du-chat syndrome), circulation cell-free fetal DNA in maternal blood (81422);
  • Unlisted molecular pathology procedure (81479); and
  • Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for reach trisomy (81507).
 
Over the Counter (OTC) Pregnancy Related Medications 

Some OTC medications may be covered by ND Medicaid if a recipient has a prescription for these medications. Some examples of these medications include: 

  • Prenatal Vitamins; 
  • Iron supplement; and
  • Aspirin 81 mg.

For up-to-date information on covered OTC medications, please refer to the Guidance Document for Active Pharmaceutical Ingredients (API) Over the Counter (OTC) Products. 

Service Authorization Requirements

Service authorizations are required when a higher level of care, not offered in North Dakota, is medically necessary. The Out-of-State policy contains additional information.

Noncovered Services

General Noncovered Services

The Noncovered Services Policy contains a general list of services that are not covered by ND Medicaid.

Non-covered obstetric services include:

  • Home births; and
  • Births at any facility not enrolled with ND Medicaid

Documentation Requirements

General Requirements

Providers must keep legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid. Records must be retained for at least 7 years after the last date the claim was paid or denied. Providers must follow the documentation requirements in the Provider Requirements Policy. 

Reimbursement Methodology and Claim Instructions

Timely Filing

ND Medicaid must receive an original Medicaid primary claim within one hundred eighty (180) days from the date of service. The time limit may be waived or extended by ND Medicaid in certain circumstances. The Timely Filing Policy contains additional information.

Third-Party Liability

Medicaid members may have one or more additional source of coverage for health services. ND Medicaid is generally the payer of last resort. Providers must pursue the availability of third-party payment sources. The Third Party Liability Policy contains additional information.

Client Share (Recipient Liability)

Client share (recipient liability) is the monthly amount a member must pay toward the cost of medical services before the Medicaid program will pay for services received. The Client Share Policy contains additional information. 

Reimbursement

A claim for services must be submitted at the provider’s usual and customary charge. Payment for services is limited to the lesser of the provider’s usual and customary charge or the ND Medicaid calculated reimbursement. 

For members with Medicaid primary, antepartum, delivery, and postpartum care must be billed separately.   

Global obstetric CPT® codes 59400, 59510, 59610, and 59618 are not covered for members with Medicaid primary coverage. They will be allowed if the member's primary insurance has paid and any coinsurance or deductible amounts remain on the claim.   

Antepartum Care 

Antepartum care includes the initial prenatal history and physical examination; subsequent prenatal history and physical examinations; documentation of weight, blood pressure, fetal heart tones, routine urinalysis; monthly visits through 28 weeks of gestation; biweekly visits through 36 weeks of gestation; and weekly visits through delivery. All antepartum care should be billed as individual evaluation and management services. CPT® 59425 and 59426 should be billed to ND Medicaid only when the member's primary insurance covers these codes.   

Delivery Services with or without Postpartum Care 

Delivery services include hospital admission, admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery. When reporting delivery-only services (59409, 59514, 59612, 59620), report inpatient postdelivery management and discharge services using E/M service codes (99238, 99239). Delivery and postpartum services (59410, 59515, 59614, 59622) include delivery services and all inpatient and outpatient postpartum services. 

Medical complications of pregnancy (e.g., cardiac and neurological conditions, diabetes, hypertension, toxemia, hyperemesis, preterm labor, premature rupture of membranes, trauma) and medical problems complicating labor and delivery management may require additional resources and may be reported separately. 

Postpartum Care Only 

Postpartum care-only services (59430) include synchronous audio-video visits, synchronous audio-only visits, brief communication technology-based services, or office or other outpatient visits following vaginal or cesarean section delivery.

Multiple Deliveries 

Providers must use the following codes when billing for multiple deliveries.

Vaginal deliveries:
  • First newborn:
    • 59409 vaginal delivery only;
    • 59410 vaginal delivery only, including postpartum care;
    • 59612 VBAC delivery only; and
    • 59614 VBAC; including postpartum care.

Use the appropriate vaginal delivery code for the first newborn. Payment will be reimbursed at 100% of the fee schedule amount.

  • Subsequent newborn(s):
    • 59409 vaginal delivery only; or 
    • 59612 VBAC delivery only.

For subsequent newborns, the appropriate vaginal delivery-only code with modifier -59 appended must be used. Payment will be reimbursed at 50% of the fee schedule for each subsequent newborn. The number of subsequent newborns must be documented in the units field and billed on a single claim.

Cesarean Delivery:
  • First newborn:
    • 59514 C-section delivery only; 
    • 59515 C-section delivery only, including postpartum care; 
    • 59620 C-section delivery only after VBAC; and 
    • 59622 C-section only after VBAC, including postpartum care.

Use the appropriate cesarean delivery code for the first newborn. Payment will be reimbursed at 100% of the fee schedule, regardless of the subsequent newborns.

  • Subsequent newborns:
    • 59514 C-section delivery only; or 
    • 59620 C-section delivery only after VBAC.

Use the appropriate cesarean delivery-only code with modifier -59 appended. Report only once regardless of the number of babies delivered.

Vaginal Delivery followed by Cesarean Delivery
  • First newborn:
    • 59409 vaginal delivery only; or
    • 59612 VBAC delivery only.

Use the appropriate cesarean delivery-only code with modifier -59 appended. Payment will be reimbursed at 50% of the fee schedule amount. 

  • Subsequent newborn(s) (C-section)
    • 59514 C-section delivery only;
    • 59515 C-section delivery only, including postpartum care; 
    • 59620 C-section delivery only after VBAC; or
    • 59622 C-section delivery only after VBAC; including postpartum care.

For the subsequent newborn(s) delivered by Cesarean, use the appropriate C-section delivery code. The primary procedure will be reimbursed at 100% of the allowable charge, and the secondary procedure at 50%. If more than one subsequent baby is delivered via C-section, report only once, regardless of the number of babies delivered.

Physician services must be billed using the CMS-1500 claim form or the 837P HIPAA compliant form. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage. 

Claim Requirements

A claim submitted by a clinical nurse specialist, a nurse practitioner, a nurse midwife, or a physician assistant must include their NPI and may not be submitted under the supervising physician's NPI.

References

Contact

Medical Services
600 East Boulevard Ave 
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov

Policy Updates

October 2026

  • Policy created