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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUniversity Health Alliance ASC Coverage Update | O…
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    CurrentUniversity Health Alliance (HSA)Policy MPP-0134-210408

    Ambulatory Surgical Center (ASC) reimbursement criteria

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    Defines University Health Alliance (UHA) reimbursement policy for Ambulatory Surgical Center services, governing when ASC services are reimbursable and the administrative/medical necessity criteria providers must meet. Affects providers submitting ASC claims to UHA.

    Policy Summary
    PayerUniversity Health Alliance (HSA)
    PolicyAmbulatory Surgical Center (ASC) reimbursement criteria
    Policy CodePolicy MPP-0134-210408
    Change TypeNo material change
    Effective DateApr 8, 2021
    Last ReviewApr 8, 2021
    Next Review Date
    Key ActionProviders may request peer-to-peer discussion or reconsideration of medical necessity determinations; prior authorization needs are guided by this payment policy.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    JCAHO/AAAHC/AAAASFrequired facility accreditations referenced
    HRS §432E-1.4statutory citation governing medical necessity
    47531example CPT listed as inappropriate
    03/16/2021

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    PAC approved date

    ASC Coverage Criteria

    ASC coverage criteria

    ASC services are covered when ALL of the following are met:

    Facility accreditation: The Ambulatory Surgical Center must be certified by The Joint Commission (JCAHO), the Accreditation Association for Ambulatory HealthCare (AAAHC), or the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).
    Statutory medical necessity: Services must meet the statutory definition of medical necessity per Hawaii Revised Statutes §432E-1.4 as applied by UHA.
    Appropriateness for ASC level of care: The procedure must be suitable for an ASC based on the patient, disease process, and the contemplated operation; suitability includes consideration of the need for monitoring and the ability to safely complete the service without hospital admission.
    Procedure-level service requirements: Time and intensity of service will be evaluated, including instruments, medication, positioning, assistance requirements, lighting, suction, cautery, sedation and monitoring needs.
    Payment assignment and documentation: Payment is by contractually assigned levels or UHA fee assignment when no contract exists; written rationale must be provided for fee assignments and comparisons to procedures with existing contractual fees must be documented.
    Exclusions and inappropriate examples: Procedures that, despite appearing on CMS ASC lists, lack an assigned fee or are inappropriate for ASC payment under UHA (example: CPT 47531) may be denied.
    Clinical discretion and peer review: UHA medical directors are available for peer-to-peer discussions and reconsideration of medical necessity determinations; providers may request reconsideration or peer-to-peer review.

    Coding and Procedure Assignment

    Example excluded/inappropriate ASC procedureCPTNot Covered
    47531Example CPT code included in CMS list but noted as inappropriate for ASC payment under this policy
    ASC assignment criteria — factors for ASC suitability
    Time and intensity of serviceConsideration of procedure time and intensity, including instruments, medication, positioning, and assistance requirements.
    Instrumentation and supportProcedures must require instrumentation, lighting, suction, cautery, sedation and monitoring not reasonably provided at a lower level of care.
    Written rationale for fee assignmentUHA requires written rationales comparing the procedure to others with contractual fees when assigning ASC payment levels.
    Peer-to-peer review availableUHA medical directors are available for peer-to-peer discussions and reviews of appropriateness determinations.
    Payment assignment basisPayment is made by contractually assigned levels or, if none exist, by UHA's good-faith fee assignment.

    Authorization, Peer Review, and Provider Responsibilities

    Prior Authorization

    Request peer-to-peer review or reconsideration for medical necessity

    Providers may request reconsideration of medical necessity determinations or ask for a peer-to-peer discussion when they disagree with UHA's application of the policy. Prior authorization needs are guided by this payment policy, but this document is a guide and not a guarantee of payment; provider contracts and member benefits may still affect payment decisions.

    • To request reconsideration, submit supporting documentation that addresses the medical necessity criteria (Hawaii Revised Statutes §432E-1.4).
    • Peer-to-peer discussions can be requested to review clinical judgment and application of ASC criteria.
    • Prior authorization requirements follow this payment policy; coverage is granted only when CPT codes meet the statutory definition of medical necessity.

    Definitions

    ASC — definition
    DefinitionAmbulatory Surgical Centers (ASCs) provide outpatient access to surgical services that can be safely accomplished without hospital admission.
    Patient and procedure selectionSelection of an ASC requires consideration of the patient, disease process, and the contemplated operation.
    Facility accreditation requirementFacility must be certified by The Joint Commission (JCAHO) and/or AAAHC and/or AAAASF to meet UHA policy requirements.
    Medical necessity — statutory reference
    Statutory referenceMedical necessity is defined by Hawaii Revised Statutes §432E-1.4 and is required for UHA reimbursement of ASC services.
    Coverage conditionCPT codes are covered when and only when they meet the statutory definition of 'medical necessity'.
    Policy Summary
    PayerUniversity Health Alliance (HSA)
    PolicyAmbulatory Surgical Center (ASC) reimbursement criteria
    Policy CodePolicy MPP-0134-210408
    Change TypeNo material change
    Effective DateApr 8, 2021
    Last ReviewApr 8, 2021
    Next Review Date
    Key ActionProviders may request peer-to-peer discussion or reconsideration of medical necessity determinations; prior authorization needs are guided by this payment policy.
    SourceLink
    On This Page
    ASC Coverage CriteriaCoding and Procedure AssignmentAuthorization, Peer Review, and Provider ResponsibilitiesDefinitions
    Policy scopeUHA reimburses for ASC services only when they are necessary as defined by the statute; appropriateness for ASC depends on clinical considerations.