Prenatal Care Provided by Primary Care Physicians — CPB 0047 | AETNA Coverage Update

Aetna modified CPB 0047 governing prenatal care by primary care physicians, effective September 26, 2025. Here's what changes for billing teams.

Aetna, a CVS Health company, updated its prenatal care coverage policy under CPB 0047 to clarify the conditions under which family physicians can bill antepartum visits using CPT 59425 and CPT 59426. If your family medicine or primary care practice sees pregnant Aetna members, this policy sets hard rules on registration, co-management, referral timing, and billing — and getting any one of them wrong means a claim denial.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Prenatal Care Provided by Primary Care Physicians
Policy Code	CPB 0047
Change Type	Modified
Effective Date	September 26, 2025
Impact Level	Medium
Specialties Affected	Family Medicine, Primary Care, OB/GYN (co-managing)
Key Action	Register your practice with Aetna as a prenatal provider and verify your antepartum billing uses CPT 59425 or 59426 before billing any visits

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Aetna Prenatal Care Coverage Criteria and Medical Necessity Requirements 2025

Aetna's prenatal care coverage policy under CPB 0047 applies specifically to family physicians providing prenatal care — not delivery — to Aetna members. Medical necessity under this policy is conditional. It doesn't apply automatically to every family practice that sees pregnant patients.

The first thing your practice must do is identify itself to Aetna as a prenatal provider. Every family practice providing prenatal services must register with Aetna and agree to follow Aetna's policies for this care. If your practice hasn't done that, your CPT 59425 and 59426 claims are at risk before you even submit them.

From there, medical necessity coverage under CPB 0047 has eight conditions your practice must meet. All eight apply every time a member chooses to stay in your practice for prenatal care instead of going directly to a participating OB.

Condition 1: Member choice must be documented. The pregnant Aetna member must be offered the choice between your practice and a participating obstetrician. Document that the member chose your practice.

Condition 2: Bill the right antepartum codes. Primary care physicians providing prenatal-only care bill CPT 59425 for four to six antepartum visits, or CPT 59426 for seven or more visits. Do not bill individual E/M codes for these visits — those won't match Aetna's fee schedule under this policy. Reimbursement ties to these two codes specifically.

Condition 3: OB co-management is mandatory. The member must choose a participating OB as a co-manager of her care. This isn't optional, and it isn't a referral you can delay — it's a condition of the coverage policy being valid at all.

Condition 4: Refer by the 28th week. The member must transfer to her selected OB no later than the 28th week visit. At that visit, the complete prenatal record must be available. If your team doesn't flag this transition in the chart, you risk billing visits after 28 weeks without coverage.

Condition 5: Ultrasound and non-stress testing go to the OB. Your practice cannot bill for limited ultrasound (from the 76801–76817 range) or fetal non-stress testing (CPT 59025). Those services must be referred to the selected OB. If you're billing these codes from a family medicine setting, expect a claim denial.

Condition 6: Fetal aneuploidy screening consent in the first trimester. Your practice is responsible for presenting the fetal aneuploidy screening consent form in the first trimester. The member signs to accept or decline. This is a documentation requirement, not a billing event — but skipping it creates compliance exposure.

Condition 7: Enroll the member in the Beginning Right Maternity Program. Your practice handles this enrollment. All genetic testing (codes 88271–88275 and 88291) gets coordinated through Aetna's Beginning Right Maternity Program, not billed independently from the primary care setting.

Condition 8: First trimester educational visit with the OB. Refer the member to the selected OB for a first trimester educational visit. This is separate from the 28th week transfer.

The policy doesn't mention prior authorization for routine antepartum visits billed under CPT 59425 or 59426, but prior authorization requirements may apply to genetic testing and ultrasound services coordinated through the maternity program. Confirm with your Aetna provider relations contact before ordering those services.

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Coverage Indications at a Glance

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Aetna Prenatal Care Exclusions and Non-Covered Services 2025

CPB 0047 draws a hard line on which services primary care practices can bill. These services are not covered when billed from the primary care setting — regardless of who orders them.

Fetal non-stress testing (CPT 59025). The policy requires your practice to refer the member to her selected OB for all fetal non-stress testing. Billing CPT 59025 from a family medicine practice under this policy will generate a denial.

Obstetrical ultrasound (CPT 76801–76817). The policy requires referral to the selected OB for all limited ultrasound services. The full obstetrical ultrasound range — CPT 76801 through 76817 — is excluded from primary care billing under CPB 0047.

Fetal biophysical profile (CPT 76818). This service falls under the same referral requirement as ultrasound and non-stress testing. Your practice cannot bill CPT 76818. It must go to the co-managing OB.

The pattern across all three exclusions is the same: these are covered services under Aetna's policy, but only when billed by or referred to the co-managing OB. Billing them from primary care doesn't just risk a denial — it signals to Aetna that your practice isn't following the co-management requirements the coverage depends on.

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Aetna Prenatal Care Billing Guidelines and Action Items 2025

These steps apply to any family medicine or primary care practice that bills Aetna for prenatal care. Work through this list before September 26, 2025.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Prenatal Care Under CPB 0047

Covered CPT Codes (When Selection Criteria Are Met)

The table below reflects codes confirmed in Aetna's formal CPB 0047 code table. CPT 59426 (antepartum care only; 7 or more visits) is referenced in the policy narrative as the billing code for seven or more antepartum visits but does not appear in the formal code table. Use it as directed by the narrative, and confirm its status with your Aetna provider relations contact if you have questions about reimbursement.

Referenced in policy narrative only (not confirmed in formal code table):

Code	Type	Description	Source Copy
59426	CPT	Antepartum care only; 7 or more visits	Policy narrative only

Note: Coverage for codes 59025, 76801–76818, 82105, 82106, and 88271–88291 requires the services to be rendered by or referred to the co-managing OB or coordinated through the Beginning Right Maternity Program. Billing these codes from the primary care setting will result in a claim denial.

Key ICD-10-CM Diagnosis Codes

The policy lists 188 ICD-10-CM codes. The table below reflects the O09 supervision of pregnancy category. The source policy assigns all O09 codes the same description: "Supervision of pregnancy [normal and high risk]." Pull the full list — including complete clinical descriptions — directly from the Aetna CPB 0047 policy document. Use these codes to support antepartum billing claims under CPT 59425 and 59426.

The full code set extends to 188 ICD-10-CM codes across the O09 series. Pull the complete list from the Aetna CPB 0047 policy document directly. Code specificity to trimester matters — don't default to unspecified codes when the chart supports trimester-specific coding.

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