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Part       AMBULATORY SURGICAL CENTERS (ASC)

317:30⊂chapter=5∂=63--565.Eligible providers

[Revised 09-12-14]
   An ambulatory surgical center (ASC) or dental ambulatory surgical center (DASC) is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. All eligible ambulatory surgical center providers must be certified by Medicare or certified through Centers for Medicare and Medicaid Services (CMS) approved accreditor for ASC and have a current contract with the Oklahoma Health Care Authority.

317:30⊂chapter=5∂=63--566.Ambulatory Surgery Center services

[Revised 02-04-10]
(a) Reimbursement. Reimbursement is made for selected services based on the Medicare approved list of covered services that can be performed at an ASC. Services not covered as Medicare ASC procedures and otherwise covered under SoonerCare may be reimbursed as determined by the OHCA. Ambulatory surgery center services are paid on a rate-per-service basis that varies according to the Health Care Procedure Coding System (HCPCS) codes. Separate payments may be made to the ASC for covered ancillary services. To be considered a covered ancillary service for which separate payment is made, the items and services must be provided integral to covered surgical procedures, that is, immediately before, during, or immediately after the covered surgical procedure.
(b) Multiple surgeries. Multiple procedures furnished during the same visit are discounted. The full amount is paid for the procedure with the highest payment rate. Fifty percent is paid for any other procedure(s) performed at the same time if the procedure is subject to discounting based on the discount indicator established by Medicare.
(c) Payment indicators. Payment indicators identify whether the service described by a HCPCS code is paid under the ASC methodology and if so, whether payment is made separately or packaged. SoonerCare follows Medicare's guidelines for packaged/bundled service costs.
(d) Minor procedures. Minor procedures that are normally performed in a physician's office are not covered in an ambulatory surgery center unless medically necessary and they are on the Medicare list for procedures approved to be performed in an ASC. Services not covered as Medicare ASC procedures and otherwise covered under SoonerCare may be reimbursed as determined by the OHCA.
(e) Dental Procedures. For OHCA payment purposes, the ASC list has been expanded to cover dental services for adults in an ICF/MR and all children.
(1) Non-emergency routine dental that is provided in an ambulatory surgery center is covered for children under the following circumstances:
(A) The child has a medical history of uncontrolled bleeding or other medical condition renders in-office treatment impossible.
(B) The child has uncontrollable behavior in the dental office even with premedication.
(C) The child needs extensive dental procedures or oral surgery procedures.
(2) Non-emergency routine dental that is provided in an ambulatory surgical center is covered for children and/or adults who are residents in ICFs/MR only under the following circumstances:
(A) A concurrent hazardous medical condition exists;
(B) The nature of the procedure requires hospitalization; or
(C) Other factors (e.g. behavioral problems due to mental impairment) necessitate hospitalization.

 

317:30⊂chapter=5∂=63--567.Coverage by category
[Revised 03-01-10]
Payment is made for ambulatory surgical center services as set forth in this Section.
(1) Children. Payment is made for children for medically necessary surgical procedures which are included on Medicare's list of covered ASC surgical procedures and dental procedures in certain circumstances. Services not covered as Medicare ASC procedures and otherwise covered under SoonerCare may be reimbursed as determined by the OHCA.
(A) Services, deemed medically necessary and allowable under federal regulations, may be covered by the EPSDT/OHCA Child Health program even though those services may not be part of the OHCA SoonerCare program. Such services must be prior authorized.
(B) Federal regulations also require the State to make the determination as to whether the service is medically necessary and do not require the provision of any items or services that the State determines are not safe and effective or which are considered experimental.
(2) Adults. Payment is made for adults for medically necessary surgical procedures which are included on Medicare's list of covered ASC surgical procedures. Services not covered as Medicare ASC procedures and otherwise covered under SoonerCare may be reimbursed as determined by the OHCA.
(3) Individuals eligible For Part B of Medicare. Payment is made utilizing the OHCA allowable for comparable services.

 

317:30⊂chapter=5∂=63--568.Elective sterilizations
[Revised 09-01-07]
Payment is made to ambulatory surgical centers for elective sterilizations performed in behalf of eligible individuals if all of the following circumstances are met:
(1) The patient must be at least 21 years of age at the time the consent form is signed,
(2) The patient must be mentally competent,
(3) A properly completed federally mandated consent for sterilization form is attached to the claim, and
(4) The form is signed and dated at least 30 days, but not more than 180 days prior to surgery.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.