For Doulas · 6 min read
Billing Rules for Doulas
A Guide to Eligibility, Visit Types, Rates & Billing Guidelines
Everything you need to know about eligibility, visit types, rates, and billing guidelines.
Billing doesn't have to be the stressful part of your work. This guide walks you through how Orka's billing system works — from confirming a client's eligibility, to understanding visit types and rates, to knowing exactly when and how visits can be billed.
Client Eligibility
Before you can bill for a visit, your client needs to have active, verified coverage. Eligibility checks happen in real time the moment you submit a client's information.
What you need to run an eligibility check
To submit a check, gather the following:
- First name & last name
- Date of birth
- Member ID (from their insurance card)
- Health plan
- Home address
Once you submit, the system checks with the payer in real time and returns a status.
Eligibility statuses
| Status | What it means |
|---|---|
| ✅ Eligible | Active coverage — visits can be billed |
| ❌ Not Eligible | No active or primary coverage found |
| ⏳ Pending | Check hasn't run yet or is processing |
| ⚠️ Errors Found | Missing info or payer rejected the request |
| 🚫 Discontinuous | Coverage end date has passed |
Important: A client must be Eligible to submit visits for billing. You can still log visits for non-eligible clients, but you won't be able to bill until eligibility is confirmed.
One More Step: Call Member Services
Here's something the eligibility check can't always catch: an "Eligible" status confirms the client has active coverage, but it doesn't always confirm that doula services are reimbursable under that specific plan, or that this plan is the right one to bill.
A few common scenarios where a client looks eligible but a claim still gets denied:
- The benefit was already used. The client worked with a previous doula and has already hit their visit cap. Reimbursed claims can be clawed back.
- The wrong network is being billed. Some plans cover certain benefits directly but delegate others — like doula services — to a partner network with its own reimbursement process.
- Secondary coverage rules. If a client has more than one health plan, only the primary payer reimburses doula services. Billing the wrong plan results in a denial.
Our system catches most of these — including secondary coverage and many ineligibility patterns — but the only way to be 100% sure is to have the client confirm with their plan directly.
📞 Before you start care, ask your client to call the member services number on the back of their insurance card. They should confirm three things:
- Is doula care a covered benefit under this plan?
- Is this plan the primary payer for doula services?
- Have any doula visits already been used under this benefit?
A five-minute phone call up front prevents denials, clawbacks, and a lot of stress down the line.
When You Can't Bill Insurance: The Superbill Option
Sometimes a client really wants to work with you, but their coverage doesn't pan out — or you'd rather not take on the denial risk for a particular case. In those situations, a superbill gives you a clean alternative.
Here's how it works:
- The client pays you directly for services at the time of care.
- You provide them with a superbill — an itemized receipt that includes the dates of service, billing codes, descriptions, and rates.
- The client submits the superbill to their insurance along with their plan's Member Claim Form.
- Reimbursement goes directly to the client, not to you.
This model keeps the denial risk on the insurance-client side rather than on you. You get paid for the work you did, and the client pursues whatever reimbursement they're entitled to.
Download a Free Superbill Template
We've put together a clean, fillable superbill template you can use with any client. It includes all the standard doula service codes, provider and client information sections, certification signatures, and notes for the client on how to submit it for reimbursement.
The template is brand-neutral, so you can use it under your own practice name.
Visit Types & Rates
Below are the current Medi-Cal rates and your payout for each visit type.
| Visit Type | Medi-Cal Rate | Your Payout |
|---|---|---|
| Initial Visit | $197.98 | $184.12 |
| Prenatal Appointment | $162.11 | $150.76 |
| Postpartum Appointment | $162.11 | $150.76 |
| Vaginal Birth Support | $685.07 | $637.11 |
| C-Section Support | $795.73 | $739.03 |
| VBAC Support | $768.69 | $714.88 |
| Extended Postpartum | $162.12/hr | $150.77/hr |
| Abortion Support | $250.85 | $233.29 |
| Miscarriage Support | $250.85 | $233.29 |
Visit Limits Per Client
Every plan has limits on how many of each visit type you can bill per client. Here's how it breaks down.
All Plans
- 1 initial visit per client
- 1 birth event per client (vaginal birth, c-section, VBAC, abortion, or miscarriage — these are mutually exclusive)
- 6 hours max of extended postpartum total (across all extended postpartum visits combined)
Commercial Plans
- 8 total prenatal + postpartum visits combined
Medi-Cal
- 8 base visits + up to 9 additional postpartum visits (17 total)
Medi-Cal Additional Visits — Requirements
To bill the additional 9 postpartum visits:
- The client's provider name, facility, practice address, and NPI must all be filled in
- You must attest that the provider signed the Medi-Cal Additional Postpartum Services Recommendation form
Same-Day Visit Rules
You can sometimes bill multiple visit types on the same day — but only in specific combinations. Here's how the categories work:
| Office Visits | Birth Events | Extended Postpartum |
|---|---|---|
| Initial Visit | Vaginal Birth | Hourly visits |
| Prenatal | C-Section / VBAC | (always allowed alongside anything) |
| Postpartum | Abortion / Miscarriage |
The three key rules
- Only 1 office visit per day. You cannot combine prenatal + postpartum, two prenatals, etc.
- Extended postpartum is always allowed alongside any other visit type, including multiples on the same day.
- On a birth day, you can also have 1 initial visit, 1 prenatal, or 1 postpartum visit.
Same-Day Combinations: Allowed vs. Not Allowed
✅ Allowed
- Initial Visit + Birth
- Prenatal + Birth
- Postpartum + Birth
- Birth + Extended Postpartum
- Prenatal + Birth + Extended Postpartum
- Postpartum + Birth + Extended Postpartum
- Prenatal + Extended Postpartum (no birth)
- Postpartum + Extended Postpartum (no birth)
- Multiple Extended Postpartum entries
❌ Not Allowed
- Prenatal + Postpartum
- Two Prenatals on the same day
- Two Postpartums on the same day
- Initial Visit + Prenatal or Postpartum
Date & Timing Restrictions
Even when a visit is otherwise valid, billing windows still apply. Keep these dates in mind:
🕐 No billing before 40 weeks pre-due date. Pregnancy wouldn't be known yet — visits before this window cannot be billed.
🕐 No billing after 12 months post-due date. The billing window has expired — visits after this point are not reimbursable.
❌ Visits older than 60 days are not accepted. The system will reject any visit submitted more than 60 days after the date of service.
🕐 Visits must fall within the insurance coverage period. Each visit is checked against the plan dates from the eligibility response.
A Quick Recap
If you remember nothing else, remember this:
- Always verify eligibility first — and ask the client to confirm coverage with member services before care begins.
- Submit visits within 60 days of the date of service.
- One office visit per day, but extended postpartum can layer on top.
- Track your visit limits so you don't run over the per-client caps.
- Use the superbill template when insurance billing isn't the right fit.
Questions?
Billing rules can feel like a lot, especially when you're just getting started. If anything is unclear or you run into a snag, our team is here for you. carina@orkahealth.co
Orka Health partners with doulas across California to expand access to perinatal care for Medi-Cal families. Learn more about working with us at orkahealth.co.