Meeting the MFM Requirement for Your Level-of-Care Designation
National guidance allows maternal-fetal medicine availability to be met by telemedicine at some levels. Several states do not. The difference decides what counts.
Medically reviewed by Sina Haeri, MD, MHSA, maternal-fetal medicine physician.
The national levels-of-maternal-care framework names telemedicine as an acceptable way to meet the maternal-fetal medicine availability criterion at Level II and Level III. Several states set conditions on top of that framework, and at least one sets a bedside response time a virtual arrangement cannot meet on its own. If your facility holds a designation or is working toward one, the question is not whether tele-MFM counts in general. It is whether it counts under your state's criteria, at your level.
What designation criteria actually test
State levels-of-maternal-care systems build on the national framework developed by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, then modify it. The criteria cover the services a facility provides, the personnel available to it, and its arrangements for consultation and transfer.
For most facilities the difficult criterion is subspecialty availability. A hospital can have the volume, the protocols and the nursing capability and still be held at a lower level because it cannot demonstrate maternal-fetal medicine availability.
What the national framework allows
The current ACOG and SMFM consensus, Obstetric Care Consensus No. 9, states the maternal-fetal medicine requirement at each level as follows. This edition replaced the 2015 consensus, and the availability language changed between the two, so check which edition any summary you have been given is quoting.
| Level | Maternal-fetal medicine availability |
|---|---|
| Level II | “An MFM readily available at all times for consultation onsite, by phone, or by telemedicine, as needed.” |
| Level III | “An MFM with inpatient privileges readily available at all times, either onsite, by phone, or by telemedicine. Timing of need to be onsite is directed by urgency of clinical situation. However, MFM must be able to be onsite to provide direct care within 24 hours.” |
| Level IV | “A board-certified MFM attending with full inpatient privileges is readily available at all times for consultation and management. This includes co-management of ICU-admitted obstetric patients.” |
Three things follow from that language.
Telemedicine is named as an acceptable route at Level II and Level III. It is not a workaround or an exception; the consensus lists it alongside onsite and phone availability.
At Level III the physician has to hold inpatient privileges at your facility, which means a consulting relationship alone does not satisfy the criterion. Privileges are usually the longer part of setting up any arrangement. How credentialing by proxy can shorten that →
And “readily available at all times” carries a physical-presence component even where telemedicine is permitted. The consensus defines the phrase as being available 24 hours a day, 7 days a week for consultation and assistance, and able to be physically present onsite within a time frame that incorporates maternal and fetal or neonatal risks and benefits with the provision of care. At Level III that expectation is given a number: onsite to provide direct care within 24 hours. A purely remote arrangement with no route to physical presence does not satisfy the criterion as written.
Levels of maternal care. Obstetric Care Consensus No. 9. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134:e41-55. Replaces Obstetric Care Consensus No. 2 (February 2015), which used different availability language and is still widely quoted. A correction was issued in April 2023. Confirm against the current edition before relying on it.
Where states set their own conditions
States are free to adopt criteria more demanding than the national framework, and several have. Texas is the clearest example and also the highest-stakes one.
Texas requires that a Level III facility have a board-certified or board-eligible maternal-fetal medicine physician with inpatient privileges available at all times for inpatient consultation, and able to arrive at the patient bedside within 30 minutes of an urgent request to co-manage patients. Telemedicine is permitted for maternal-fetal medicine co-management in non-urgent inpatient situations where an in-person response is not required, subject to a written compliance plan, a patient consent process, and an MFM physician who holds active facility privileges and participates in onsite care and quality review.
The rule then says in terms: “The use of telemedicine for on call consultation does not substitute for the requirement of maternal fetal medicine availability for in-person consultation on complex and critically ill patients on a regular basis.”
The stakes in Texas are not only clinical. Since 1 September 2021, Texas Medicaid has reimbursed hospitals for inpatient and outpatient maternal services only where the hospital holds a maternal level-of-care designation from the Department of State Health Services. Claims from hospitals without a designation on file are denied, with an exception for emergency services to stabilize a patient before transport to a facility that can provide the appropriate level of care.
A hospital in a state that adopts the national language and a hospital in Texas can look identical on paper and face entirely different requirements. Read your own state's rule before you plan around either.
25 Texas Administrative Code § 133.208(d)(5), Maternal Designation Level III, as amended effective 8 January 2023. Texas Medicaid provider notice, maternal level of care designation required, effective 1 September 2021. State rules change on their own schedule. Confirm current text with your state designation authority.
What to confirm before you assume the answer
- Which body designates in your state: the health department, ACOG's verification program, or an accreditor?
- What does your state's criteria language say about MFM availability at your current level and the level above it?
- Does that language distinguish between availability for consultation and physical presence?
- Is there a maximum response or bedside arrival time, and does it apply to urgent requests only?
- Does the criterion require inpatient privileges at your facility?
- Is designation tied to reimbursement or licensure in your state?
- When is your next survey or reverification?
How Ouma fits
Ouma is a physician practice licensed to practice in all 50 states, providing board-certified maternal-fetal medicine consultation, inpatient support and ultrasound interpretation. Ouma also operates in-person maternal-fetal medicine practices acquired in the Northeast, so coverage is not virtual-only.
For a hospital working toward or defending a designation, the useful question is narrower than “can you help.” It is whether a specific arrangement, in your state, at your level, produces the documented availability and the privileges your criteria require, and whether it survives a survey. Where your state permits telemedicine, that is usually straightforward. Where your state requires physical presence within a set time, the answer depends on geography and is worth working through rather than assuming either way.
Send us your state's criteria language and we will tell you plainly whether we think it fits.
How a tele-MFM program gets stood up → · What coverage costs →
Frequently asked questions
Does telemedicine satisfy the MFM requirement for a Level III designation?
Under the national ACOG and SMFM framework, yes at Level II and Level III, provided the physician holds inpatient privileges at the facility and can be onsite to provide direct care within 24 hours. Several states are stricter. Texas, for example, requires an MFM to arrive at the bedside within 30 minutes of an urgent request and states that telemedicine for on-call consultation does not substitute for in-person consultation on complex and critically ill patients.
Does the MFM need inpatient privileges at our hospital?
At Level III the national framework requires it, and Texas requires it as well. A consulting relationship without privileges does not satisfy the criterion. Credentialing by proxy under 42 CFR 482.22 is often the fastest route to privileges for a distant-site telemedicine physician.
Can a hospital lose Medicaid payment without a maternal designation?
In Texas, yes. Since 1 September 2021, Texas Medicaid reimburses inpatient and outpatient maternal services only where the hospital holds a maternal level-of-care designation, with an exception for emergency stabilization before transfer. Whether designation is tied to payment in your state is one of the first things to confirm.
Who decides whether our arrangement satisfies the criteria?
Your state's designation authority, through its survey or verification process. A vendor cannot make that determination for you, which is why the criteria language and the survey history matter more than a vendor's description of its own model.
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