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.
