016-27-20 Ark. Code R. § 2

Current through Register Vol. 49, No. 6, June, 2024

Rule 016.27.20-002 - Ambulatory Surgical Center Manual (ASC-1-19)

Section II

Ambulatory Surgical Center

222.000ASC Procedures That Require Medical Review, Prior Authorization, and Diagnosis Code Restriction

A. The procedure codes found in the following link require medical review, prior authorization, or diagnosis restriction as of the effective date indicated. View or print the procedure codes for ASC services.

B. For dates of service on or after November 1, 2017 the following procedure codes require prior authorization.

Outpatient Surgery Abortion Codes That Require Prior Authorization

59840 59841 59866

1. Refer to Section 216.110, "Abortion When Life of Mother Would Be Endangered If the Fetus Were Carried to Term," for the prior authorization process.

2. Refer to Section 216.120, "Abortion When the Pregnancy Is a Result of Rape or Incest," for the prior authorization process.

3. Abortion claims must be billed on a paper CMS-1450 (UB-04) claim form with the DMS-2698 form (Certification Statement for Abortion), history and physical, and operative report attached.View a sample CMS-1450 (UB-04) claim form. View or print form DMS-2698.

016.27.20 Ark. Code R. § 002

Adopted by Arkansas Register Volume MMXX Number 11, Effective 6/1/2020