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(1) These requirements are in addition to those requirements contained in ARM 37.85.401 through 37.85.414.

(2) Clinic services must be provided by a clinic which is licensed as an outpatient facility by the appropriate licensing entity of the state where the facility is located and meet the requirement for participation in Medicare.

(3) Clinic services must be provided by, or under the direction of a licensed physician or, where appropriate a licensed dentist.

(4) Conditions for coverage of listed ambulatory surgical center procedures:

(a) Subject to the exclusions in (b), covered surgical procedures are surgical procedures that would not be expected to pose a significant safety risk to a member when performed in an ambulatory surgical center and for which standard medical practice dictates that the member would not typically be expected to require active medical monitoring more than 24 hours following an admission. Active medical monitoring includes the monitoring or assessment of respiratory function, cardiovascular function, mental status, pain, temperature, or post-operative hydration at least every 30 minutes.

(b) Covered surgical procedures do not include those that:

(i) generally result in extensive blood loss;

(ii) requires a major or prolonged invasion of body cavities;

(iii) directly involves major blood vessels;

(iv) are generally emergency or life threatening in nature; or

(v) can safely be performed in a physician's or dentist's office.

(c) Covered surgical procedures can only be rendered by a licensed ambulatory surgical center.

(5) Telephone contacts are not a clinic service.


History: 53-2-201, 53-6-113, MCA; IMP, 53-6-101, 53-6-141, MCA; NEW, 1982 MAR p. 1695, Eff. 9/17/82; AMD, 1989 MAR p. 877, Eff. 6/30/89; AMD, 1989 MAR p. 1850, Eff. 11/10/90; AMD, 1990 MAR p. 740, Eff. 3/16/90; AMD, 1991 MAR p. 1032, Eff. 7/1/91; AMD, 1992 MAR p. 1404, Eff. 7/1/92; AMD, 1994 MAR p. 313, Eff. 2/11/94; AMD, 1997 MAR p. 548, Eff. 3/25/97; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 1664, Eff. 6/30/00; AMD, 2014 MAR p. 1409, Eff. 7/1/14; AMD, 2019 MAR p. 341, Eff. 3/30/19.

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