Current through Register Vol. 49, No. 9, September, 2024
RULE 111
CRANIOFACIAL ANOMALY RECONSTRUCTIVE SURGERY COVERAGE
"WENDELYN'S CRANIOFACIAL LAW"
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 and recommended treatment under Ark. Code Ann. §
23-79-1501
et seq. This Rule is also issued to implement Act 955 of 2021, "An Act to
Modify the Law Concerning Craniofacial Coverage and to Establish Wendelyn's
Craniofacial Law" (hereafter. Act 955, formerly codified from Act 1226 of 2013
and Act 373 of 2015).
SECTION
2.
DEFINITIONS
For purposes of this Rule, the following definitions will
apply:
(1) "acquired craniofacial
anomaly" means a craniofacial condition caused or brought on only by trauma or
tumor.
(2) "craniofacial anomaly"
means the abnormal development of the skull and face.
(3) "healthcare service" means a healthcare
procedure, treatment, or service provided by a medical provider.
(4) "medical provider" means a person who
performs healthcare services for patients with a craniofacial
anomaly.
(5) "nonurgent" healthcare
service means any craniofacial healthcare service which is not
urgent.
(6) "reconstructive
surgery" means the use of surgery to alter the form and function of cranial
facial tissues due to a congenital or acquired musculoskeletal disorder,
including surgery to alter the form and function of the skull and
face.
(7) "surgical team member"
means a surgical member of an American Cleft Palate-Craniofacial Association
("ACPA") approved team who specializes in craniofacial anomaly reconstructive
surgery or a surgical member of an approved team with requisite and equivalent
craniofacial surgical experience in the field of service requested to be
reviewed.
(8) "urgent healthcare
service" means a craniofacial healthcare service for a non-lifethreatening
condition that, in the opinion of a provider with knowledge of a craniofacial
patient's medical condition, requires prompt medical care in order to prevent:
(A) A serious threat to life, limb, or
eyesight;
(B) Worsening impairment
of a bodily function that threatens the body's ability to regain maximum
function;
(C) Worsening dysfunction
or damage of any bodily organ or part that threatens the body's ability to
recover from the dysfunction or damage; or
(D) Severe pain that cannot be managed
without prompt medical care.
SECTION 3.
COVERAGE REQUIREMENTS FOR
HEALTH INSURERS UNDER THIS RULE
(a)
Health insurers shall be subject to all Sections of this Rule.
(b) Pursuant to Ark. Code Ann. §
23-79-1502(b),
a health benefit plan shall provide coverage for dental and vision care as
approved by an ACPA approved surgical team member following the requirements of
this section.
(c) A health benefit
plan shall include coverage for the following:
(1) On an annual basis, or during the course
of a year:
(A) Sclera contact lenses,
including coatings;
(B) Office
visits;
(C) An ocular impression of
each eye;
(D) Autologous serum eye
drops;
(E) eye weights, either
surgically and/or external eye weights in one or both eyes as directed by an
eye specialist, as needed;
(2)
(A)
Every two (2) years, two (2) hearing aids and two (2) hearing aid molds for
each ear.
(B) As used in this
section, "hearing aids" includes behind the ear, in the ear, wearable bone
conductions, surgically implanted bone conduction services, and cochlear
implants; and
(d) A health benefit plan, or any third-party
administrator for the plan, shall not require mail order, walkin clinics, or
in-network protocols, for compliance with any audiology or other services, as
mandated by this Rule.
(e) Any
additional tests or procedures that are medically necessary for a craniofacial
patient and any diagnostic service incidental to the provision of these
benefits in this Section.
(f) For
healthcare services to be performed by a nationally approved cleft-craniofacial
team, or recommended healthcare services to be performed by a medical provider
that is not on a nationally approved cleft-craniofacial team, a request for
written authorization or approval shall be reviewed by the administrator
(health insurer) of the health benefit plan:
(A) Within two (2) working days from the
request by a nationally approved cleft-craniofacial surgical team member, or by
a medical provider that is not on a nationally approved cleft-craniofacial team
if the request is accompanied by an Attestation in the form established by this
Rule that is signed by a surgical team member of an APCA Approved Team, for a
nonurgent case; or
(B) Within
twenty-four (24) hours from the request by a nationally approved
cleft-craniofacial surgical team member, or by a medical provider that is not
on a nationally approved cleft-craniofacial team if the request is accompanied
by an Attestation in the form established by this Rule that is signed by a
surgical team member of an APCA Approved Team for an urgent case. The health
insurer must be familiar with or willing to become familiar with the particular
craniofacial diagnoses in question and recommended procedure prior to making a
determination. The standards in this section shall follow the Prior
Authorization Transparency Initiative.
SECTION 4.
MEDICAL PROVIDER OFFICE
REQUIREMENTS FOR ACPA APPROVED TEAMS
(a) Medical Provider Office Requirements for
ACPA Approved Teams.
(b) For
healthcare services that are recommended by a surgical member of a nationally
approved cleft-craniofacial team, a request for written authorization shall be
submitted to the health benefit plan:
(A) At
least two (2) working days before the proposed service date, by a nationally
approved cleft-craniofacial surgical team, for a nonurgent case; or
(B) At least twenty-four (24) hours before
the proposed services date, by a nationally approved cleft-craniofacial
surgical team member, for an urgent case.
(c) Every needed serviee or reeommended
procedure shall be authorized by an Attestation in the form established by this
Rule that is signed by a surgical team member of an APCA Approved team, and
thereafter be monitored under the coordinated treatment plan until the
completion of such services by the nationally approved cleft-craniofacial
surgical team member.
(d) The
standards in this section shall follow the Prior Authorization Transparency
Initiative.
SECTION 5.
MEDICAL PROVIDER OFFICE REQUIREMENTS FOR NON ACPA APPROVED TEAM
MEMBERS
(a) Medical Provider Office
Requirements for Non APCA Approved Team members. A medical provider that is not
on a nationally approved cleft craniofacial team shall communicate and respond
within two (2) working days from the request to any medical information
requests made by the nationally approved cleft-craniofacial surgical team
member who made the recommendation described in this Rule.
(b) For healthcare services that are
recommended by a surgical team member of a nationally approved
cleft-craniofacial team that are to be performed by a medical provider that is
not on a nationally approved cleft-craniofacial team, a request for written
authorization or approval shall be submitted to the health benefit plan:
(i) At least two (2) working days before the
proposed service date as recommended by a nationally approved
cleft-craniofacial surgical team member, for a nonurgent case; or
(ii) Within twenty-four (24) hours before the
proposed service date as recommended by a nationally approved
cleft-craniofacial surgical team member, for an urgent case.
(c) The recommended needed
services shall be the subject of an attestation delivered by a surgical team
member of an APCA Approved Team to the medical provider and thereafter be
monitored under the coordinated treatment plan until the completion of such
services by the nationally approved cleft-craniofacial surgical team
member.
(d) A medical provider that
is not on a nationally approved cleft-craniofacial team shall comply with
Section 7 for referrals for services.
(e) The standards in this section shall
follow the Prior Authorization Transparency Initiative.
(f) For claims to be admitted or paid under
this Section, for purposes of this Section, a medical provider that is not on a
nationally approved cleft-craniofacial team shall submit to the health benefit
plan a signed attestation form (Exhibit "A") by a surgical team member of an
ACPA Approved Team. The health benefit plan shall have two (2) working days
from the submission date to review such claim(s) for nonurgent cases and
twenty-four (24) hours for urgent cases.
SECTION 6.
CODING FEE FOR
EVALUATION
Every health benefit plan covering residents or enrollees in
this State shall cover charges for evaluations performed by a nationally
approved cleft-craniofacial team in its review of proposed services under
Section Five (5) of this Rule. The coding designation number and fee amount for
such charges shall be the same for all health benefit plans pursuant to an
explanatory bulletin by the Commissioner which will be issued annually or as
needed.
SECTION 7.
ATTESTATION OR AUTHORIZATION FORM
For services to be reviewed under Section Five (5) of this
Rule, the medical provider that is not on a nationally approved
cleft-craniofacial team shall use the Attestation or Authorization form which
shall be designated as Wendelyn's Craniofacial Law Authorization Form as
Exhibit "A" to this Rule.
APPENDIX A
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