Simply Healthcare & Clear Health Alliance 2027 Maternity Policy

In Florida, Simply Healthcare Plans, Inc. (Simply) covers members through two programs: 

Statewide Medicaid Managed Care (SMMC) and Florida Healthy Kids (FHK). 

Its sister plan, Clear Health Alliance (CHA), serves members under SMMC. 

Both plans follow the same approach to maternity billing. They pay for care across the whole pregnancy, which includes:

• Antepartum visits, 
• Labor management, 
• The delivery itself, and 
• Postpartum follow-up. 

The caps on routine antepartum visits and outpatient postpartum evaluation and management (E/M) visits are meant for routine pregnancies only. When a patient has a high-risk pregnancy or an active pregnancy-related complication, the antepartum limit no longer applies to those E/M services. 

How Antepartum Care Is Billed and Limited in Florida ?

Billing for antepartum care starts with one basic rule: every prenatal visit is reported as its own encounter, using the appropriate E/M code with modifier TH attached. Under this policy, a routine pregnancy can have up to 13 office or outpatient E/M visits paid in one pregnancy episode, as long as every visit is billed under the same federal tax identification number (TIN). 

That count begins with the very first prenatal visit after the pregnancy is confirmed, so it isn’t treated as a freebie outside the limit. This first visit also has a coding detail that’s easy to miss. The claim needs an ICD-10-CM code from category Z3A that shows how many weeks of gestation the patient has completed, and without it, the visit won’t be reimbursed.

What If Obstetric Care Moves to a Different TIN from Florida OB Care?

Patients sometimes change doctors partway through a pregnancy, and the visit limit follows the TIN, not the patient. If a member moves her obstetric care from Florida to a provider or group that bills under a different TIN, the new practice gets its own routine antepartum visit limit for the care it provides. On the other hand, if she switches between physicians or other qualified healthcare professionals who all bill under the same TIN, nothing resets, and the original count continues.

Billing Rules in Florida for Labor Management

When a patient is being managed through labor, the service should be billed with one of the CPT® codes from 59080 through 59083. There is a cap to keep in mind, though. The plan pays for only one labor management service per calendar date in each setting. If more than one could apply on the same day, reimbursement goes to the highest level that fits the care provided.

Coding Requirements for Delivery

For the delivery itself, providers should use whichever of these CPT codes matches the service: 59431, 59432, 59502, or 59503. Picking the right delivery code isn’t the only step, though. Every professional delivery claim also needs an ICD-10-CM code from category Z3A that shows how many weeks of gestation were completed at the time of delivery. If that code is missing, the claim won’t be paid.

How Postpartum Care Is Billed in Florida for 2027

Postpartum visits follow the same pattern as prenatal ones when billing. As each visit is billed its own encounter, using the appropriate E/M code with modifier TH attached.

For routine cases, the plan covers up to three office or outpatient E/M visits in the 12 weeks after delivery, as long as they’re billed under the same TIN. These visits also share an overall cap with the prenatal ones. Under the same TIN, routine antepartum and outpatient postpartum visits together can’t go beyond 16 in one pregnancy episode. One thing providers don’t need to worry about here is the Z3A code. Unlike the first prenatal visit and the delivery claim, postpartum E/M claims can be submitted without it.

What the Medical Record Needs to Show As Documentation

Every maternity claim should be backed up by the patient’s medical record. The documentation needs to support each of these details:

• The code that was billed
• The date of service
• The place of service
• Which phase of maternity care the visit falls under
• The E/M level, or the complexity of labor management
• Any modifier the policy requires
• Any diagnosis used to justify going beyond the routine visit limits
• Any procedure or service billed separately

It’s worth keeping these records in good order, because the plan can ask for them at any time. It also has the right to review claims either before payment goes out or after it has already been made.

E/M Codes for Prenatal and Postpartum Office Visits

Routine prenatal and postpartum visits in an office or outpatient setting are billed with the standard E/M codes. Which range you use depends on whether the patient is new to the practice or already established.

• 99202 through 99205 (new patient): These cover office or other outpatient E/M services for a new patient. Modifier TH must be added, and the visit limits and any applicable Z3A requirements still apply.
• 99211 through 99215 (established patient): These cover office or other outpatient E/M services for an established patient. Modifier TH is required here as well, along with the same visit limits and applicable Z3A requirements.

Separately Reimbursable Maternity Services Under Florida Medicaid in 2027

Starting January 1, 2027, Simply and Clear Health Alliance will not fold every pregnancy-related service into the reimbursement for the main maternity service. The following services fall outside that payment and may be eligible for separate reimbursement:

• Pregnancy confirmation: A visit to confirm the pregnancy qualifies for separate reimbursement when billed with the appropriate E/M or preventive medicine code, as long as prenatal care doesn’t begin during that same encounter. This visit also doesn’t count toward the 13 routine antepartum visits.
• Extra prenatal visits for high-risk cases: Antepartum E/M visits beyond the routine limit of 13 are eligible for reimbursement when the diagnosis codes show a high-risk pregnancy or an active pregnancy-related complication.
• E/M service before labor admission: A significant, separately identifiable E/M service performed at another site before the patient is admitted for labor management can be reimbursed separately when billed with modifier 25.
• Labor management on the delivery date: When labor management is actually provided on the same calendar date as the delivery, it qualifies for its own reimbursement.
• Hospital E/M before a planned primary C-section: Inpatient or observation E/M services on the same date as a planned primary cesarean delivery are reimbursable when the patient is not in labor.
• Placenta delivery or minor repairs by a different provider: Repair of a first- or second-degree episiotomy or laceration (CPT 59300), or delivery of the placenta (CPT 59414), is eligible for separate reimbursement when someone other than the professional billing the vaginal delivery performs it.
• Third- or fourth-degree repairs: Repair of a third- or fourth-degree episiotomy or laceration (CPT 59433 or 59434) is reimbursable along with CPT 59431 or 59432 when it’s done at the time of vaginal delivery.
• Hysterectomy during a C-section: A subtotal or total hysterectomy performed in the same operative session as a cesarean delivery is reimbursed under CPT 59504. If the same physician bills both the cesarean and the hysterectomy, modifier 51 is required.
• Extra postpartum visits for complications: Outpatient postpartum E/M visits beyond the routine limit of three, under the same TIN, are eligible for reimbursement when the diagnosis codes show a pregnancy-related or postpartum complication.
• Uterine tamponade: When the procedure is actually performed, it qualifies for reimbursement under CPT 59623.

Maternity Services Not Separately Reimbursable Under Florida Medicaid in 2027

Under the policy taking effect January 1, 2027, some services are already covered by the reimbursement for the main maternity service in Florida, while others simply don’t qualify for payment on their own. Simply and Clear Health Alliance will not issue separate reimbursement for the following:

• Routine prenatal visits beyond 13: Antepartum office or outpatient E/M visits that go past 13 in one pregnancy episode, under the same TIN, are not reimbursed for routine pregnancies.
• Services bundled into the prenatal E/M visit: For both routine and high-risk pregnancies, the services below are covered by the reimbursement for the antepartum office or outpatient E/M visit. They won’t be paid separately when billed on the same calendar date, with a maternity diagnosis, and under the same TIN as that visit:
  • Routine urinalysis and point-of-care urine testing: 81000, 81001, 81002, 81003, 81015
  • Urine pregnancy testing: 81025
  • Preventive counseling: 99401 through 99404
  • Self-management education: 98960 through 98962
  • Prenatal and lactation education: S9443, S9445
  • Behavioral screening: 96127
  • Depression screening: G0444
  • Health-risk assessments: 96160, 96161
  • For Prolonged E/M services code99417, G2212
  • Remote physiologic monitoring setup and device supply code 99453, 99454
  • Tobacco cessation services: 99406, 99407
• Multiple labor management services on one day: Only one labor management service is reimbursed per calendar date in the same setting. If more than one level is billed, reimbursement is limited to the highest level that applies.
• Care that’s part of labor management: Interim physical exams, collecting and interpreting physiologic data, maternal and fetal monitoring, and labor induction or augmentation are all considered part of labor management and are not reimbursed on their own.
• Labor management for a planned C-section: When a cesarean delivery is scheduled or planned and the patient is not in labor, labor management is not reimbursable.
• Immediate postpartum care on the delivery date: Postpartum care given on the same calendar date as the delivery is covered by the delivery reimbursement.
• Same-day discharge management: Hospital inpatient or observation discharge day management isn’t reimbursed separately when the patient goes home on the same calendar date as the delivery.
• Placenta delivery and minor repairs by the delivering provider: When the same physician or other qualified healthcare professional who bills the vaginal delivery also delivers the placenta or repairs a first- or second-degree episiotomy or laceration, those services are included in the vaginal delivery reimbursement.
• Hospital E/M on the date of a repeat C-section: Initial or subsequent inpatient or observation E/M services billed on the same calendar date as a repeat cesarean delivery are not reimbursed separately.
• Routine postpartum visits beyond three: Postpartum office or outpatient E/M visits that go past three in the 12 weeks after delivery, under the same TIN, are not reimbursed for routine cases.
• Uterine tamponade with medication only: If hemorrhage is managed only with medication, uterine tamponade is not reimbursable.
• Duplicate or overlapping services: Any maternity care service that duplicates or overlaps with another is not eligible for reimbursement.

What This Means for Your Practice

• Count routine prenatal and postpartum visits per patient under each TIN. Once a patient reaches 13 antepartum visits, 3 postpartum visits, or 16 combined, the next routine visit will not be paid unless the diagnosis shows a high-risk pregnancy or a complication.
• Add modifier TH to every antepartum and postpartum E/M claim, whether you’re billing 99202 through 99205 or 99211 through 99215. Put a Z3A code on the first prenatal visit and on every professional delivery claim, but leave it off postpartum E/M claims.
• Stop billing 81002, 81025, 96127, G0444, 99401 through 99404, and the other bundled services on the same date as a prenatal E/M visit. They are paid as part of that visit for both routine and high-risk pregnancies.
• Check who performed the placenta delivery or the first- or second-degree repair. If it was the provider billing the vaginal delivery, 59414 and 59300 are not payable. If it was someone else, bill them separately.

Getting these basics right now means fewer denials and smoother payments once the policy takes effect on January 1, 2027.

Support Maternity Billing With BillingFreedom

Changes like this one can easily disrupt cash flow for OB/GYN practices that are still billing the old way. BillingFreedom helps Florida practices stay ahead of payer updates by tracking visit limits, applying the right modifiers and Z3A codes, and checking claims against bundling rules before they go out. Our OB/GYN billing services are built to keep your maternity claims clean and compliant from the first prenatal visit through postpartum care. 

For more information, feel free to contact us at info@billingfreedom.com to get your practice ready for 2027.

Source: Simply Healthcare Plans, Inc. and Clear Health Alliance, Maternity Services Reimbursement Policy (G-14001),