RULE 054.00.15-004 - Rule 111: Craniofacial Anomaly Reconstructive Surgery Coverage

RULE 054.00.15-004. Rule 111: Craniofacial Anomaly Reconstructive Surgery Coverage

SECTION 1. AUTHORITY

This Rule is issued pursuant to Ark. Code Ann. § 23-79-1503 which requires the Arkansas Insurance Department ("AID") to issue rules for the implementation and administration of coverage for craniofacial anomaly reconstructive surgery under Ark. Code Ann. § 23-79-1501 etseq.

SECTION 2. DEFINITIONS

Unless otherwise separately defined in this rule and consistent with state law, the terms or phrases as used in this rule shall follow the definitions of such terms or phrases as defined in Ark. Code Ann. § 23-79-1501.

SECTION 3. COVERAGE REQUIREMENT REVIEW

(a) Pursuant to Ark. Code Ann. § 23-79-1502(a)(l), a health benefit plan that is offered, issued, provided, or renewed in this state shall include coverage and benefits for reconstructive surgery and related medical care for a person of any age who is diagnosed as having a craniofacial anomaly if the reconstructive surgery and treatment are medically necessary to improve a functional impairment that results from the craniofacial anomaly as determined by a nationally approved cleft-craniofacial team, approved by the American Cleft Palate-Craniofacial Association ("ACPA approved team") in Chapel Hill, North Carolina.

(1) The services included in the coverage and benefits for reconstructive surgery and related medical care may be performed in this state by providers in an ACPA approved team that has diagnosed a craniofacial anomaly, or may be performed by licensed and qualified specialist in this state not in an ACPA approved team as long as such specialist has received:

(i) a diagnosis or evaluation that the patient has a craniofacial anomaly by an ACPA approved team;

(ii) a written authorization or approval of the proposed services and treatment plan by an ACPA approved team, including approval of any additional services or care, subsequent to the treatment plan;

(iii) the licensed and qualified specialist agrees it must maintain clinical records and provide appropriate documentation whenever requested by an ACPA approved team;

(iv) the licensed and qualified specialist must be willing to allow the member(s) of the ACPA approved team to closely oversee all treatment(s); and

(v) the licensed and qualified medical specialist must also agree to the ACPA team providing ongoing review for all authorized services including accepting any limitations or withdrawal of such approvals depending on the outcome and medical needs and care of the patient.

(2) Due to the limited number of ACPA approved teams in this state needed to perform diagnoses and review surgery treatment plans for patients with craniofacial anomalies at this time, an ACPA approved team outside this state may provide the evaluation, authorizations and review as required in Section Three (3) (a)(l)(i)-(v) of this rule. Nothing in this rule is intended to require a health benefit plan to provide coverage and benefits for reconstructive surgery services themselves to be performed outside this state.

(b) Pursuant to Ark. Code Ann. § 23-79-1502(b), a health benefit plan shall also provide coverage for dental and vision care as approved by an ACPA approved team following the requirements of this section.

SECTION 4. EFFECTIVE DATE

The effective date of this Rule is November 23, 2015.

(11/21/2016)

The following state regulations pages link to this page.