Billing Claims Questionnaire

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Midwife’s Name

Member’s Name

Member’s DOB

Last Menstrual Cycle

Member’s Address

Name of Insurance (Ignore is a VOB is on file)

Member ID

Group Number

Policy Holder’s Name

Policy Holder’s DOB

Delivery Date

Did the member have a home birth or a birth center birth?

List capillary draw dates

List venipunture draw dates

Was aquatherapy used for labor management?

Was nitrous oxide used for labor management?

IV therapy. If yes, how many minutes?

Did the member experience a postpartum complication. IF so, what complication?

Rhogam injection dates with NDC number

Was a foley catheter utilized?

Did the member require oxygen therapy?

If the member had a birth center admission, what was the admission date/time and discharge date/time?

Name of Newborn

Newborn Gender

Time of birth

Was a birth assistant present?

If a vitamin k was administered IM what is the NDC?

Did newborn require rescusitation?

Did newborn require oxygen therapy?

Newborn home visit dates

Newborn office visit dates

Metabolic Screen Dates

Bilirubin test dates (if applicable)

Please list individual prenatal visit dates

Please list individual postpartum visit dates

IF Mother transferred to the hospital during labor, please list the date and hours spent with the member until transfer

IF Mother transferred to the hospital during labor, please list the date and hours spent with the member at the hospital

Did the member receive massage therapy in house? IF so, please list the dates

NST Dates (If applicable)

What is the total amount billed to the patient for maternity care?

What is the total amount paid by the patient as of today’s date?

Date of Physician Initial Consult (for oversight fee and date of chart review/if applicable)

Additional notes (if needed)

Name of individual submitting the form

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