Simply / CHA Multiple Delivery Billing : Modifier 51 and 22 Rules for Florida Medicaid

Billing for multiple births with Simply Healthcare Plans, Inc. (Simply) and Clear Health Alliance (CHA) follows a specific reimbursement policy, Multiple Delivery Services (G-06044). Both plans hold Florida Medicaid contracts, and Simply also serves members through Florida Healthy Kids. Before getting into the delivery rules, it helps to understand the general conditions Simply and CHA attach to every reimbursement policy. Since printed copies can fall out of date, the plans also ask providers to confirm the latest version on their provider websites.

Simply Healthcare and Clear Health Alliance Reimbursement Conditions in Florida

Simply and CHA describe their reimbursement policies as a guide to help providers submit claims accurately. They also explain how reimbursement is decided when a service is covered under the member’s benefit plan. These rules apply to both participating and non-participating professional providers and facilities, unless a specific policy says otherwise.

Providers are expected to follow proper billing and submission guidelines and use industry standard, compliant codes on every claim. That means billing with CPT codes, HCPCS codes, and/or revenue codes that reflect the services or procedures actually performed. Every code billed must be fully supported in the medical record or office notes.

What If a Service Is Covered but Still Not Reimbursed?

This can happen. Simply and CHA make it clear that coverage under a member’s benefit plan does not guarantee reimbursement. The service must still meet authorization and medical necessity guidelines that fit the procedure and diagnosis, as well as the member’s state of residence.

What If Coding or Billing Guidelines Aren’t Followed?

When claims don’t follow correct coding and billing guidelines or current reimbursement policies, Simply and CHA may take any of these actions:

• Reject or deny the claim
• Recover or recoup the reimbursement already paid
• Adjust the reimbursement so it reflects the services or procedures that were actually performed

What If a Contract or Mandate Says Something Different?

In that case, the mandate may come first. Requirements in provider, state, federal, or Centers for Medicare & Medicaid Services (CMS) contracts may supersede these reimbursement policies. Simply and CHA say they try to keep delays in policy implementation to a minimum, but if a delay does occur, they can still recoup or recover reimbursement back to the policy’s effective date. The plans can also review and revise their policies whenever needed and will publish the most current version on their website after each update.

Multiple Delivery Reimbursement Rules in Florida

Simply allows reimbursement for multiple births delivered by a combined-delivery method, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. When a multiple birth involves vaginal or cesarean deliveries performed using a combined-delivery method, professional reimbursement follows two separate rules based on the type of delivery:

• Vaginal deliveries: Vaginal deliveries involved in multiple births should be billed with modifier 51, and multiple procedure guidelines will apply.
• Cesarean deliveries: Cesarean deliveries involved in multiple births should be billed with modifier 22, and multiple procedure guidelines will not apply.

What If All Multiple Deliveries Use the Same Delivery Method?

In this case, Simply does not allow separate reimbursement. When multiple deliveries are performed by the same delivery method, the additional deliveries are not reimbursed separately.

Related Simply Healthcare Policies for Multiple Delivery Billing in Florida

Simply and CHA connect the Multiple Delivery Services policy to several other reimbursement policies and materials. Providers billing multiple deliveries can review these alongside it:

• Maternity Services in relation to multiple deliveries
• Modifier 22
• Modifiers 25 and 57: Evaluation and Management with Global Procedures
• Modifiers 50 and 51: Multiple and Bilateral Surgery
• Modifiers 59, XE, XP, XS, XU: Distinct Procedural Services
• Modifiers 80, 81, 82, and AS: Assistant at Surgery
• Modifier Usage
• Professional Anesthesia Services

What This Means for Your Practice

• Append modifier 51 to vaginal deliveries in a combined-delivery multiple birth.
• Append modifier 22 to cesarean deliveries in a combined-delivery multiple birth, and don’t expect multiple procedure guidelines to apply to that reimbursement.
• Hold back separate charges for additional deliveries when every baby in a multiple birth is delivered by the same-delivery method.
• Check provider, state, federal, and CMS contract requirements against policy G-06044, and confirm every CPT, HCPCS, or revenue code is supported in the medical record before submitting.

Getting these modifier rules right on the first submission is what keeps multiple delivery claims from being denied, recouped, or adjusted later.

Support Multiple Delivery Billing With BillingFreedom

When a multiple birth involves both vaginal and cesarean deliveries, one wrong modifier can turn a clean claim into a denial or a recoupment months later.

Multiple delivery claims leave little room for modifier errors. This is where BillingFreedom helps practices get them right before they reach the payer. Our OBGYN medical billing team reviews delivery documentation, applies accurate modifiers according to Simply and CHA rules, and follows up on any claim that comes back denied or underpaid.

Reach us at info@billingfreedom.com or +1 (855) 415-3472. Accurate delivery claims, steady reimbursement!

Source: Simply Healthcare Plans, Inc. and Clear Health Alliance, Reimbursement Policy: Multiple Delivery Services (G-06044), published November 2024