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ASC State Regulatory Profiles — Volume 1

Northeast and Mid-Atlantic — Licensure, Facility Categories, Need Review, and Utilization Review Law in Twelve Jurisdictions

The first volume of the GoHealthcare ASC State Regulatory Profiles series. It provides a verified, citation-level profile of ambulatory surgical facility regulation in Connecticut, Delaware, the District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont — covering licensing authority, statutory and regulatory citations, facility categories and the thresholds that determine them, need review, accreditation interaction, notable operational requirements, and applicable Medicare and state utilization review law.

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Important Notice — Read Before Use

This document is an educational and operational reference. It is not medical advice, legal advice, coding advice, or a substitute for physician clinical judgment, official CMS guidance, accreditation standards, state licensure requirements, or the applicable payer's own written policy.

Coverage rules, payment rates, quality reporting requirements, prior authorization criteria, state law, and coding conventions change frequently and often without broad notice. Every code, policy citation, effective date, and payment figure must be independently verified against the current primary source before it is relied upon for a clinical, billing, contracting, or compliance decision.

Publication Information

Document Control

Document Title	ASC State Regulatory Profiles — Volume 1 — Northeast and Mid-Atlantic — Licensure, Facility Categories, Need Review, and Utilization Review Law in Twelve Jurisdictions
Series	GoHealthcare MSK Specialty Procedure Library™ — ASC Specialty Hub
Document Identifier	GH-MSK-HUB-ASC-P13
Standard Applied	GoHealthcare Clinical Procedure Guide Standard v1.0
Publication Date	August 3, 2026
Document Version	Version 1.0
Developed By	GoHealthcare Practice Solutions, under the leadership of Pinky Maniri, Founder and Chief Executive Officer

ASC Specialty Hub

Purpose, Audience, and Sources

Purpose	Provide ASC leaders, developers, counsel, and multi-state operators with a verified starting point for state regulatory research in the Northeast and Mid-Atlantic, and a consistent profile structure that can be extended across the remaining volumes.
Primary Audience	Physicians; ASC administrators, developers, and executives; healthcare counsel; prior authorization and utilization management teams; revenue cycle leaders; multi-state operators; compliance officers
Credentials	MSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance
Primary Sources	State statutes and administrative codes as cited per jurisdiction; state licensing agency published materials; National Academy for State Health Policy 50-state certificate-of-need database updated December 12, 2025; CMS ASC Prior Authorization Demonstration and WISeR Model materials; 42 CFR Part 416, Subpart C
Scope Exclusions	This volume does not state legal conclusions, does not opine on the lawfulness of any structure or arrangement, and does not substitute for primary state legal research or advice from counsel licensed in the relevant jurisdiction. Statutory and regulatory citations are provided as verified research starting points and are subject to amendment, renumbering, and readoption. Where a profile states that a requirement was not identified, that means it was not located in the sources consulted, not that it does not exist.
Website	https://www.gohealthcarellc.com

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ASC Specialty Hub — Page Index

This page is one of thirteen in the GoHealthcare Ambulatory Surgery Center Specialty Hub. Each page is written to stand alone for the team that owns that domain, and to connect to the domains upstream and downstream of it.

#	Knowledge Center page	#	Knowledge Center page
01	Specialty Overview	08	KPIs and Metrics
02	Practice Operations	09	AI Applications
03	Prior Authorization	10	Best Practices
04	Revenue Cycle	11	Procedure Links
05	Documentation	12	Frequently Asked Questions
06	Coding	13	State Regulatory Reference ◀ you are here
07	Compliance

ASC State Regulatory Series

• State Regulatory Reference
• Volume 1 - Northeast and Mid-Atlantic
• Volume Two - South and Southeast
• Volume Three - Midwest and Great Plains
• Volume Four - West, Southwest and Non-Contiguous

On This Page

Explore This Guide

Use the links below to move directly to each section.

Core Guidance

1. Scope and Method of This Volume
2. Connecticut
3. Delaware
4. District of Columbia
5. Maine
6. Maryland
7. Massachusetts
8. New Hampshire
9. New Jersey
10. New York
11. Pennsylvania

References, Governance and Supporting Material

12. Rhode Island
13. Vermont
14. Volume 1 Comparative Summary
15. Regional Operating Observations
16. Series Roadmap
17. Key Takeaways
18. References
19. Related GoHealthcare Resources
20. Document History
21. Educational Disclaimer and Terms of Use

01

ASC Specialty Hub

Scope and Method of This Volume

This volume is the first of four in the GoHealthcare ASC State Regulatory Profiles series. It covers twelve Northeast and Mid-Atlantic jurisdictions: Connecticut, Delaware, the District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.

Each profile records the licensing authority, the statutory and regulatory citations governing ambulatory surgical facility licensure, the definitional thresholds that determine which category a facility falls into, the need-review regime and its applicability to ambulatory surgery specifically, the interaction between accreditation and licensure, notable operational requirements that differ from the federal Conditions for Coverage, and the Medicare prior authorization programs and state utilization review law that apply.

Verification Standard for This Volume

Each citation in this volume was located in a primary or official state source — state code, administrative code, or the licensing agency's own published materials — during preparation. State statutes and administrative rules are amended continuously and are frequently renumbered or readopted.

This volume is a research starting point and an orientation, not legal advice and not a substitute for primary state legal research. Before committing capital, filing an application, scheduling a case in a new jurisdiction, or relying on any threshold or exemption stated here, confirm the current text of the cited provision with the state agency and obtain review by qualified healthcare counsel licensed in that jurisdiction.

Where a profile states that a requirement was not identified, that means it was not located in the sources consulted — not that it does not exist.

1.1 What Each Profile Field Means

Field	What it records
Licensing authority	The agency that issues and enforces the facility license, and the statutory grant of authority
Licensure regulation	The administrative code chapter or part containing the operating standards
Facility categories	How the state classifies ambulatory surgical facilities, and the thresholds that determine category — operating room count, ownership, anesthesia level, or procedure type
Need review	Certificate of need, determination of need, determination of coverage, or equivalent — the reviewing body and how it reaches ambulatory surgery
Accreditation interaction	Whether accreditation is required, substitutes for licensure survey, or is a condition of continued licensure
Notable operational requirements	Requirements that differ from or add to the federal Conditions for Coverage — transfer agreements, reporting, patient age limits, ownership disclosure, physical plant standards
Medicare prior authorization	Participation in the CMS ASC Prior Authorization Demonstration, the WISeR Model, or both
State utilization review law	Decision timelines, gold carding, AI restrictions, and related enactments identified

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Connecticut

Licensing authority	Department of Public Health. Licensure required under Conn. Gen. Stat. § 19a-491 (license and certificate required; fees; minimum service quality standards). The governing definitional and licensure provision for this facility type is Conn. Gen. Stat. § 19a-493b.
Facility category	"Outpatient surgical facility" — defined at § 19a-493b(a) as any entity other than a hospital providing surgical services or diagnostic procedures involving moderate or deep sedation, moderate or deep analgesia, or general anesthesia, as those levels are defined by the American Society of Anesthesiologists or another accrediting entity recognized by DPH.
Medical office exemption	A medical office owned and operated exclusively by physicians licensed under § 20-13 is excluded if it satisfies all five conditions: no operating room or designated surgical area; bills no facility fees to third-party payers; administers no deep sedation or general anesthesia; performs only minor surgical procedures incidental to the office practice; and uses only light or moderate sedation or analgesia for those procedures.
Need review	Certificate of need under Conn. Gen. Stat. ch. 368z, administered by the Health Systems Planning Unit of the Office of Health Strategy. P.A. 18-91 moved this function from the Office of Health Care Access division of DPH to OHS, effective May 2018. New outpatient surgical facilities must obtain a determination from the department addressing whether a CON is required.
Transfer of ownership	Section 19a-493b provides a conditional exception to the § 19a-638(a) transfer or change of control CON requirement where the facility is owned and controlled exclusively by physicians licensed under § 20-13, directly or through specified entity forms, and the other statutory conditions are satisfied.
Dental clinics	Section 19a-493b expressly does not reach dental clinics.
Medicare prior authorization	Not a WISeR state. Not an ASC Prior Authorization Demonstration state.
State utilization review law	No AI-in-utilization-review enactment identified in the sources consulted. Verify current session activity.

Operational Note

Connecticut's regulatory trigger is the anesthesia level, not the operating room count. A practice that begins administering deep sedation or general anesthesia may cross into outpatient surgical facility status — and therefore into licensure and CON jurisdiction — without any change to its physical plant. Track anesthesia practice as a regulatory variable, not only a clinical one.

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Delaware

Licensing authority	Department of Health and Social Services, Division of Health Care Quality. Statutory authority at 16 Del. C. § 122(3)(p).
Licensure regulation	16 DE Admin. Code 4405, Free Standing Surgical Centers. The regulation was revised through rulemaking finalized December 1, 2021, with the stated purpose of aligning requirements with federal requirements and nationally recognized standards of practice and updating licensure language.
Facility category	"Free standing surgical center" (FSSC). Delaware separately regulates office-based surgery: 16 Del. C. § 122(3)y defines office-based surgery and § 122(3)z addresses accreditation or licensure of the facility. Under 24 Del. C. § 1705, a licensed practitioner may not perform office-based surgery in a facility unless that facility is accredited or licensed accordingly.

Extended stay	The regulation contemplates FSSCs accommodating patient stays of 23 hours and 59 minutes; applicants seeking to do so must obtain written approval from the local government having jurisdiction certifying that the proposed use does not conflict with zoning restrictions, deed restrictions, and local noise ordinances, prior to applying for licensure.
Need review	Delaware maintains a certificate of need program — the Certificate of Public Review process, administered through the Delaware Health Resources Board. Confirm current applicability, thresholds, and exemptions for ambulatory surgical facilities directly with the Board.
Medicare prior authorization	Not a WISeR state. Not an ASC Prior Authorization Demonstration state.
State utilization review law	Prior authorization decision timeline legislation enacted. No AI-in-utilization-review enactment identified in the sources consulted.

Operational Note

The 23-hour-59-minute extended stay pathway with a local land-use approval precondition is unusual and is worth confirming early in site selection. It is the kind of requirement that surfaces after a lease is signed if it is not screened at the outset.

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District of Columbia

Licensing authority	DC Health — Health Care Facilities Division. The Division conducts on-site surveys for health, safety, sanitation, fire, and quality of care requirements and identifies deficiencies affecting District licensure and federal program eligibility.
Licensure statute	D.C. Ambulatory Surgical Treatment Center Licensure Act, D.C. Law 2-66, codified at D.C. Code Title 44, Chapter 5, Subchapter I-A (Ambulatory Surgical Treatment Center Licensure), Part B (Licensure of Ambulatory Surgical Treatment Centers). Facility licensure generally also operates under the Health Care and Community Residence Facility, Hospice and Home Care Licensure Act of 1983, D.C. Law 5-48.
Facility definition	"Ambulatory Surgical Treatment Center" — any institution, place, or building devoted primarily to the maintenance and operation of facilities for the performance of surgical procedures on an outpatient basis, including facilities where family planning procedures are performed. The facility may not provide beds or other accommodations for overnight stay. Patients must be discharged in an ambulatory condition without danger to continued well-being, or transferred to a hospital.
Need review	Certificate of need applies in the District. The definitional reference in the licensure framework points to D.C. Law 3-99. Confirm current administering body, thresholds, and ambulatory surgery applicability with the District's health planning authority.
Medicare prior authorization	Not a WISeR state. Not an ASC Prior Authorization Demonstration state. Note that Maryland, Pennsylvania, and New York — all within the regional referral pattern — are demonstration states, so a multi-site organization operating across the District line may face different requirements at facilities a short distance apart.
State utilization review law	No AI-in-utilization-review enactment identified in the sources consulted.

Operational Note

The District's statutory definition is explicit that an ambulatory surgical treatment center may not provide beds or accommodations for overnight stay. That is a narrower formulation than the federal 24-hour expectation and should be read alongside it when designing recovery capacity.

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Maine

Licensing authority	Department of Health and Human Services, Division of Licensing and Certification. Maine states that ambulatory surgical centers must be both licensed by the State and federally certified.
Licensure regulation	10-144 CMR Chapter 125, Regulations Governing the Licensing of Ambulatory Surgical Facilities.
Need review	Certificate of need under 22 M.R.S.A. Chapter 103-A, administered through the Department's Healthcare Oversight program. Certain actions require CON review above a threshold amount, and many thresholds are indexed annually for inflation. A letter of intent describing the project and its costs must be submitted to the CON program at least 30 days before the application. Procedural rules appear at 10-144 CMR Ch. 501 (Maine Certificate of Need Act Limitation) and Ch. 503 (Certificate of Need Procedures Manual for Health Care Facilities other than nursing care facilities); appropriateness review procedures at Ch. 505.
Sentinel event reporting	22 M.R.S.A. § 8753 requires hospitals and all facilities under their license, ambulatory surgical centers, and end stage renal disease facilities to report sentinel events to the Division of Licensing and Certification. Sentinel events are defined in 10-144 CMR Ch. 114, Rules Governing the Reporting of Sentinel Events.
Certificate of Public Advantage	Separate regime under the Hospital and Health Care Provider Cooperation Act, 22 M.R.S.A. Chapter 405-A, permitting certain cooperative agreements.
Medicare prior authorization	Not a WISeR state. Not an ASC Prior Authorization Demonstration state.
State utilization review law	No AI-in-utilization-review enactment identified in the sources consulted.

Operational Note

The 30-day letter of intent requirement in advance of a CON application is a scheduling constraint on any Maine development timeline and is easy to overlook when working backward from a target opening date. The annually indexed thresholds should be re-verified each year rather than carried forward.

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Maryland

Licensing authority	Maryland Department of Health, Office of Health Care Quality (OHCQ). OHCQ conducts initial licensure surveys, annual surveys, relocation surveys, change of ownership review, and complaint investigations.
Licensure regulation	COMAR 10.05.01 (freestanding ambulatory care facilities, general) and COMAR 10.05.05 (Freestanding Ambulatory Surgical Facilities). Licensing procedure at COMAR 10.05.05.03, which provides for a nonrefundable $1,000 fee for a three-year period on initial application and on renewal.
Two-tier facility structure	"Freestanding ambulatory surgical facility" at COMAR 10.05.05.01 is the general licensure category and contains two sub-categories that are treated very differently for need review. An ambulatory surgery center (ASC) has procedure rooms only, or procedure rooms and up to two operating rooms, and proceeds by Determination of Coverage. An ambulatory surgical facility (ASF) contains three or more operating rooms, is a statutorily defined health care facility, and requires a Certificate of Need.

Need review	Maryland Health Care Commission (MHCC). Prior to applying to OHCQ for a license, the applicant must first obtain either a CON or a Determination of Coverage from MHCC. Procedural regulations at COMAR 10.24.01, including COMAR 10.24.01.05 addressing determination of coverage and data reporting; State Health Plan for General Surgical Services at COMAR 10.24.11. The statutory definition of "ambulatory surgical facility" at Health-General § 19-114(b) was changed effective October 1, 2019.
Operating room expansion	Under COMAR 10.24.01.05, an ambulatory surgical facility or other entity primarily providing ambulatory surgical services may not relocate beyond an adjacent site or expand its number of operating rooms after June 1, 1995 without obtaining a Certificate of Need, except as permitted in the CON or exemption criteria in the State Health Plan.
Determination of coverage scope	A determination of coverage letter is issued only for the exact address specified and only for the person specified. A change in address before the facility is built or established requires a new determination; a change in ownership requires a new determination.
Dental exemption	A CON is not required for ambulatory surgical services provided as part of a dental office practicing dentistry, if the facility is not used in a medical practice other than dentistry.
Transfer and referral	Emergency transfer policy compliant with COMAR 10.05.05.09 is expected, and transfer and referral agreements with a hospital appear in CON review records as supporting documentation.
Public charge information	Under the State Health Plan general standards at COMAR 10.24.11.05A, each ambulatory surgery center, ambulatory surgical facility, and hospital is expected to make information concerning charges for the full range of surgical services available to the public.
Cosmetic surgical facilities	Separate category — defined at COMAR 10.12.03.01 and licensed under COMAR 10.12.03.02.
Medicare prior authorization	ASC Prior Authorization Demonstration Phase 1 state. Requests accepted from January 5, 2026 for dates of service on or after January 19, 2026. Not a WISeR state.
State utilization review law	AI-in-utilization-review legislation enacted. Verify current text and effective date.

Operational Note

Maryland's two-operating-room line is the single most consequential planning threshold in the state. A center designed with two operating rooms proceeds by Determination of Coverage; the third operating room converts the project into a Certificate of Need matter with a materially longer and more contested process. Design decisions made for clinical throughput reasons therefore carry a regulatory consequence that should be modeled before the floor plan is fixed.

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Massachusetts

Licensing authority	Department of Public Health. Ambulatory surgery is licensed within the clinic licensure framework rather than as a standalone facility type.
Licensure regulation	105 CMR 140.000, Licensure of Clinics. Application evaluation at 105 CMR 140.108. Surgical service is defined at 105 CMR 140.020 as providing diagnosis or care through endoscopic procedures or operative procedures requiring regional or general anesthesia.
Statutory basis	M.G.L. c. 111, §§ 51–53. All providers of ambulatory care must be appropriately licensed as a clinic or hospital satellite before beginning service, unless exempt from facility licensure under M.G.L. c. 111, § 52.

Need review	Determination of Need under 105 CMR 100.000. Under 105 CMR 100.730, no person may be issued an original license to establish or maintain a freestanding ambulatory surgery center unless DPH has first issued a Notice of Determination of Need for the proposed project at the designated location. Proposed projects inclusive of ambulatory surgery are addressed at 105 CMR 100.715(B)(2). Under 105 CMR 140.108(C), the Department will not approve an original license or the addition of a satellite unit unless need has been determined where the facility is subject to determination of need.
Reporting obligations	Ambulatory surgery center reporting of serious reportable events and serious adverse drug events at 105 CMR 140.308; healthcare-associated infection data collection, submission, and reporting at 105 CMR 140.309.
Transaction oversight	H.5159, signed January 2025, substantially expanded DPH authority to monitor healthcare transactions and providers, with particular emphasis on private equity investment, broadened the transaction reporting framework to reach nearly all transaction types, and for the first time imposed post-transaction monitoring lasting up to five years after closing. ASCs have been subject to transaction and data reporting obligations since 2015. The law also introduced a new office-based surgical center licensure category; DPH guidance clarifying applicability was pending.
Health Policy Commission	Notice of material change and cost and market impact review obligations under 958 CMR 7.00, with amended material change categories including significant capacity expansions.
Medicare prior authorization	Not a WISeR state. Not an ASC Prior Authorization Demonstration state.
State utilization review law	No AI-in-utilization-review enactment identified in the sources consulted. The Governor has publicly proposed 24-hour turnaround for urgent prior authorization requests and elimination of prior authorization for certain conditions; confirm current status before relying on it.

Operational Note

Two Massachusetts features deserve early attention. First, ambulatory surgery is licensed as a clinic, which means the operating standards a Massachusetts center is measured against are not organized as an ASC-specific chapter and must be read out of the clinic regulation. Second, the post-transaction monitoring window introduced by H.5159 extends oversight for up to five years after a closing — a consideration that belongs in transaction diligence and in the projected cost of any ownership change.

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New Hampshire

Licensing authority	Department of Health and Human Services. Licensure under RSA 151; an applicant seeks a license to operate an ASC pursuant to RSA 151:2, I(d).
Licensure regulation	New Hampshire Code of Administrative Rules He-P 812, Ambulatory Surgical Centers. A revised rule was adopted July 30, 2024; confirm the currently effective version and its expiration date.
Facility definition	"Ambulatory surgical center" — any building, place, or portion thereof, exclusive of physician's or dentist's offices, that maintains and operates services for the performance of outpatient surgical procedures.
Anesthesiologist qualification	He-P 812 defines anesthesiologist as a physician licensed to practice medicine in New Hampshire who is accredited by the American Board of Anesthesiology, the American College of Anesthesiology, or the American Osteopathic Board of Anesthesiology.
Non-compliance framework	The rule defines an area of non-compliance as any action or failure to act causing a licensee to be out of compliance with RSA 151, He-P 812, or other federal or state requirements — a formulation that incorporates federal Conditions for Coverage failures into the state licensure enforcement framework.

Need review	New Hampshire is a non-CON jurisdiction; the state's certificate of need program was repealed. Confirm that no successor review requirement applies to the specific project.
Medicare prior authorization	Not a WISeR state. Not an ASC Prior Authorization Demonstration state.
State utilization review law	No AI-in-utilization-review enactment identified in the sources consulted.

Operational Note

He-P 812's non-compliance definition folds federal requirements into the state licensure standard. In practical terms that means a Conditions for Coverage deficiency is available to the state as a licensure matter, and a center should not assume that federal and state findings run on separate tracks.

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New Jersey

Licensing authority	Department of Health, Certificate of Need and Licensing Division, Office of Certificate of Need and Healthcare Facility Licensure. Statutory authority at N.J.S.A. 26:2H-1 et seq., specifically 26:2H-5.
Licensure regulation	N.J.A.C. 8:43A, Manual of Standards for Licensing of Ambulatory Care Facilities — the licensing standards applicable to all ambulatory care facilities, covering definitions and qualifications, licensure procedures, and operating standards. Physical plant and functional requirements at N.J.A.C. 8:43A-19.1 et seq.; waiver mechanism at N.J.A.C. 8:43A-2.9. General licensure procedures and enforcement at N.J.A.C. 8:43E.
Licensure and Conditions for Coverage	N.J.A.C. 8:43A-3.12 addresses reporting for ambulatory surgery facilities, including an annual audited statement of compliance with the access requirements specified in the facility's certificate of need approval letter. The regulation contemplates a survey against 42 C.F.R. Part 416 performed and reported to the Department within the twelve months following receipt of a twelve-month temporary license, with a full license withheld pending that submission.
Surgical practice category	Under N.J.S.A. 26:2H-12, as amended by P.L.2017, c.283, surgical practices in operation on the enactment date were required to apply for licensure as ambulatory care facilities providing surgical and related services. A surgical practice certified by CMS as an ASC provider is not required to meet the N.J.A.C. 8:43A-19.1 physical plant and functional requirements; the same relief extends to certain accredited practices in operation on the enactment date.
Assessment exposure	P.L.2025, c.70 (A5809), the Healthcare Finance Enhancement Act signed June 30, 2025, significantly expanded the universe of New Jersey ASCs subject to annual assessments and changed the economics of those assessments. Beginning in 2026, one-room surgical practices previously exempt from assessment are no longer exempt. The ambulatory care facility assessment is at N.J.S.A. 26:2H-18.57.
Pending legislative change	A5828 as introduced would replace the licensure requirement for surgical practices with a registration requirement carrying a $1,000 fee effective for five years. Confirm current status before relying on either framework.
Need review	Certificate of need under N.J.A.C. 8:33, Certificate of Need Application and Review Process, with facility-and service-specific chapters including N.J.A.C. 8:33E for cardiac services.
Medicare prior authorization	WISeR Model state. Not an ASC Prior Authorization Demonstration state.
State utilization review law	S1255 requires payers to honor prior authorization approvals for the duration of the treatment course rather than re-authorizing at intervals. Confirm current text and applicability.

Operational Note

New Jersey is the jurisdiction in this volume where the economics of the regulatory framework are moving fastest. The 2025 assessment expansion reaches facilities that were previously outside it, the one-room exemption ends in 2026, and a pending bill would restructure surgical practice oversight from licensure to registration. Any New Jersey financial model built on a pre-2025 assessment assumption should be rebuilt.

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New York

Licensing authority	Department of Health. Ambulatory surgery facilities are established and operated under Public Health Law Article 28, with approval by the Public Health and Health Planning Council.
Licensure regulation	10 NYCRR Part 755, Free-standing and Off-site Hospital-based Ambulatory Surgery Services — statutory authority Public Health Law § 2803. Part 755 covers ambulatory surgery definition (755.1), administrative requirements (755.2), surgery services (755.3), anesthesia services (755.4), nursing services (755.5), patient admission and discharge (755.6), medical record system (755.7), emergency care (755.8), quality assurance (755.9), and data requirements (755.10). Part 755 applies to free-standing ASCs and off-site hospital-based ASCs.
Facility definition	An ambulatory surgery service is organized to provide surgical procedures that need to be performed for safety reasons in an operating room on anesthetized patients requiring a stay of less than 24 hours. The definition expressly excludes outpatient surgical procedures that can be safely performed in a private physician's office or an outpatient treatment room.
Construction standards	Minimum construction standards of a diagnostic and treatment center under Article 28, at 10 NYCRR § 715.16.
Need review	Certificate of need. Need methodology for ambulatory surgery at 10 NYCRR § 709.5, under which need is demonstrated through documentation that the proposed capacity will be utilized sufficiently to be financially feasible, as shown by a three-year analysis of projected costs and revenues. The Department finalized changes to the CON review process effective August 6, 2025 amending § 710.1, and a proposal to raise capital expenditure thresholds — for ASCs and clinics from $6 million to $8 million — has been under consideration.
Accreditation	Free-standing ASCs must become accredited by a national accrediting organization within two years of Public Health and Health Planning Council approval.
Reporting	Adverse event reporting to NYPORTS and procedure and payer information reporting to SPARCS.
Office-based surgery boundary	An Article 28 facility, including an ASC regulated under Part 755, is a hospital as defined in PHL Article 28; surgery performed in an ASC is therefore not office-based surgery under PHL § 230-d. An Article 28 licensed facility may not share space with an office-based surgery practice.
Medicare prior authorization	ASC Prior Authorization Demonstration Phase 1 state. Requests accepted from January 5, 2026 for dates of service on or after January 19, 2026. Not a WISeR state.
State utilization review law	No AI-in-utilization-review enactment identified in the sources consulted.

Operational Note

The prohibition on co-location between an Article 28 ASC and an office-based surgery practice is a recurring structural problem for physician groups that want to operate both models from one address. It should be resolved at the real estate and entity-structure stage, not at licensure.

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Pennsylvania

Licensing authority	Department of Health, with authority to license ambulatory surgical facilities under the Health Care Facilities Act, 35 P.S. §§ 448.101—448.904b. License applications are made in accordance with section 807 of the act, 35 P.S. § 448.807.
Licensure regulation	28 Pa. Code, Part IV, Subpart F — Ambulatory Surgical Facilities, Chapters 551 through 571: general information (551); ownership, governance and management (553); medical staff (555); quality assurance and improvement (557); nursing services (559); pharmaceutical services (561); medical records (563); laboratory and radiology services (565); environmental services (567); fire and safety services (569); and construction standards (571). General health facility provisions at 28 Pa. Code Chapter 51.
Class structure	Pennsylvania classifies ASFs as Class A, B, or C. Under 28 Pa. Code § 551.31, a license is not required to operate a Class A ASF, but the facility must be accredited by AAAHC, The Joint Commission, AAAASF, or another nationally recognized accrediting agency acknowledged by the Medicare program in order to be identified as providing ambulatory surgery, and must register with the Department and provide specified information annually. A facility moving from Class B to Class C must request and obtain a license before providing services to ASF Class III or PS-III patients.
Applicability	Under 28 Pa. Code § 551.1, only facilities licensed under the subpart may provide ambulatory surgery in the Commonwealth, except as provided for Class A facilities. The subpart does not apply to outpatient surgery performed at licensed hospitals, or to dentist or oral surgeon offices except to the extent those offices seek ASF licensure.
Patient age limit	A child under six months of age may not be treated in an ASF.
Construction standards	28 Pa. Code § 571.1 sets minimum standards by reference to the Guidelines for Design and Construction of Hospitals and of Outpatient Facilities published by the Facility Guidelines Institute. Exceptions are requested under 28 Pa. Code § 51.33 and are published in the Pennsylvania Bulletin.
Survey delegation	Under 28 Pa. Code § 551.33, the Department may designate nationally recognized accrediting agencies whose standards are at least as stringent as the Department's to perform some or all aspects of licensure surveys. The survey includes an on-site inspection and review of written approvals from agencies responsible for building, electric, fire, and environmental safety.
Need review	Pennsylvania is a non-CON jurisdiction for these purposes. Note that 28 Pa. Code Chapter 401 addresses a Certificate of Need Program and Chapter 301 addresses limitation on federal participation for capital expenditures; confirm current operative status with the Department.
Medicare prior authorization	ASC Prior Authorization Demonstration Phase 1 state. Requests accepted from January 5, 2026 for dates of service on or after January 19, 2026. Not a WISeR state.
State utilization review law	No AI-in-utilization-review enactment identified in the sources consulted.

Operational Note

Pennsylvania's Class A pathway — registration plus accreditation in lieu of licensure — is one of the more distinctive structures in the country and can materially change development timeline and cost. It also means that the class determination, which follows from patient physical status and procedure classification, is a regulatory decision with licensure consequences. Confirm class at the outset and re-confirm whenever the case mix or patient acuity moves.

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Rhode Island

Licensing authority	Department of Health. Regulations promulgated under the authority of R.I. Gen. Laws § 23-17-10, with facility licensure governed by R.I. Gen. Laws Chapter 23-17, Licensing of Healthcare Facilities.
Licensure regulation	216-RICR-40-10-5, Licensing of Freestanding Ambulatory Surgical Centers, for FASCs; and 216-RICR-40-10-13, Licensure of Physician Ambulatory Surgery Centers and Podiatry Ambulatory Surgery Centers, for physician-and podiatry-owned centers. Related: 216-RICR-40-10-3, Organized Ambulatory Care Facilities.
Two-track structure	Rhode Island distinguishes freestanding ambulatory surgical centers from physician ambulatory surgery centers and podiatry ambulatory surgery centers, the latter defined as an office or portion of an office owned or operated by a physician-controlled professional services corporation or a private physician's office or group, used to furnish surgical services to the owner's or operator's own patients. Both single-practice and multi-practice forms exist.
Accreditation as a licensure condition	Under 216-RICR-40-10-13, a physician or podiatry ASC must file an acceptable application with an accreditation agency within nine months of initial licensure, attain certification from an accreditation agency within twenty-four months of initial licensure, and maintain that certification as a condition of licensure.
Ownership disclosure	A notarized listing of names and addresses of direct and indirect owners — individual, partnership, or corporate — with ownership percentages designated must accompany the licensure application and be updated annually, and must include each owner of any mortgage, deed of trust, note, or other obligation. Financial interest disclosure is separately addressed at R.I. Gen. Laws § 23-17-46.
License term	Licenses expire at the end of the calendar year unless renewed; renewal applications must be submitted one month prior to expiration.
Need review	Determination of need under the state's health care certificate of need framework, with the Health Services Council reviewing and the Director of Health approving. A Letter of Intent must be submitted before the CON application to the Center for Health Systems Policy and Regulation, and both are prerequisites to licensure. A change in owner, operator, or lessee requires prior Health Services Council review and licensing agency approval through a Change in Effective Control application. Establishment and CON approval of a multi-practice physician or podiatry ASC likewise requires Health Services Council review and Director approval; single-practice physician and podiatry centers are treated differently under the determination of need regulation.
Operating room safety	R.I. Gen. Laws § 23-17-49.1 requires evacuation of surgical smoke plume in operating rooms.
Medicare prior authorization	Not a WISeR state. Not an ASC Prior Authorization Demonstration state.
State utilization review law	Prior authorization eliminated for routine primary care services ordered by a primary care physician under a three-year pilot beginning October 1, 2025.

Operational Note

Rhode Island's single-practice versus multi-practice distinction is the pivotal structural question. It determines whether a physician-owned center enters the determination of need process at all. Entity structure and the intended referral and ownership model should be settled before a Letter of Intent is filed, because the classification follows from them.

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Vermont

Need review authority	Green Mountain Care Board. Certificate of need under 18 V.S.A. Chapter 221. Health care facilities must obtain Board approval before undertaking significant capital investments, purchasing high-cost equipment, or adding new services that exceed specified monetary thresholds.
Threshold change	Act 15 of 2025, effective May 13, 2025, raises the monetary thresholds that trigger CON review. Confirm the current thresholds with the Board before assuming a project is below review.
Facility definition	Under 18 V.S.A. § 9432, to be considered an ambulatory surgical center a facility must satisfy all of the stated criteria, including that it charges or intends to charge a facility fee in addition to professional fees for the services performed, and that it has an operating room or recovery room in the facility. A dental office limited to dentistry and oral or maxillofacial surgical procedures is not deemed an ambulatory surgical center for purposes of the subchapter.
Licensure	Facility licensure and survey functions sit with the Vermont Department of Health and the Division of Licensing and Protection within the Agency of Human Services. Confirm the current licensure pathway and any ASC-specific rule directly with the State; the operative requirement for Medicare participation is certification against 42 CFR Part 416.
Practical market note	Vermont's CON process for ambulatory surgery has historically been contested, with hospital and hospital association opposition featuring in ASC applications. Development timelines should be planned accordingly.
Medicare prior authorization	Not a WISeR state. Not an ASC Prior Authorization Demonstration state.
State utilization review law	Gold carding statute active. Confirm the qualifying threshold, look-back period, and exemption duration.

Operational Note

The Vermont ASC definition turns in part on whether the facility charges or intends to charge a facility fee. That makes the billing model itself a definitional element — a consideration when structuring a physician-office-based surgical program that is not intended to enter the ambulatory surgical center regime.

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Volume 1 Comparative Summary

Jurisdiction	Licensure citation	Need review	Medicare PA
Connecticut	Conn. Gen. Stat. §§ 19a-491, 19a-493b; DPH	CON — Health Systems Planning Unit, Office of Health Strategy	--
Delaware	16 Del. C. § 122(3)(p); 16 DE Admin. Code 4405; DHSS/DHCQ	Certificate of Public Review — Delaware Health Resources Board	--
District of Columbia	D.C. Law 2-66; D.C. Code tit. 44, ch. 5, subch. I-A; DC Health	CON — confirm current administering body	--
Maine	10-144 CMR Ch. 125; DHHS Division of Licensing and Certification	CON — 22 M.R.S.A. ch. 103-A; 30-day letter of intent	--
Maryland	COMAR 10.05.01 and 10.05.05; OHCQ	MHCC — DOC if 2 or fewer ORs; CON if 3 or more ORs	ASC Demo Phase 1
Massachusetts	105 CMR 140.000 (clinic licensure); M.G.L. c. 111 §§ 51–53; DPH	Determination of Need — 105 CMR 100.000	--

Jurisdiction	Licensure citation	Need review	Medicare PA
New Hampshire	RSA 151:2, I(d); He-P 812; DHHS	Non-CON	--
New Jersey	N.J.S.A. 26:2H-1 et seq.; N.J.A.C. 8:43A; DOH	CON — N.J.A.C. 8:33	WISeR
New York	PHL Article 28; 10 NYCRR Part 755; DOH	CON — need methodology at 10 NYCRR § 709.5	ASC Demo Phase 1
Pennsylvania	35 P.S. §§ 448.101—448.904b; 28 Pa. Code ch. 551—571; DOH	Non-CON; Class A registration pathway	ASC Demo Phase 1
Rhode Island	R.I. Gen. Laws ch. 23-17; 216-RICR-40-10-5 and -13; DOH	CON — Health Services Council; LOI prerequisite	--
Vermont	18 V.S.A. ch. 221 (need); confirm licensure pathway with the State	CON — Green Mountain Care Board; Act 15 of 2025 thresholds	--

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Regional Operating Observations

• The regulatory trigger differs by state and it is rarely the operating room count alone. Connecticut turns on anesthesia level, Maryland on operating room count, Vermont in part on whether a facility fee is charged, Pennsylvania on patient physical status class, and Rhode Island on single-practice versus multi-practice ownership. A development model built on one state's trigger will misclassify facilities in the others.
• Three of the twelve jurisdictions are ASC Prior Authorization Demonstration states — Maryland, New York, and Pennsylvania — and New Jersey is a WISeR state. A multi-site organization in this region can face three different Medicare prior authorization postures within a two-hour drive.
• Accreditation is a licensure condition, not merely a payer expectation, in several states. New York requires accreditation within two years of Council approval; Rhode Island requires application within nine months and certification within twenty-four months for physician and podiatry centers; Pennsylvania Class A facilities are accredited in lieu of licensure.
• Ownership disclosure obligations exceed the federal patient-rights requirement in places. Rhode Island requires an annually updated notarized ownership listing extending to holders of mortgages, deeds of trust, and notes.
• Transaction and post-closing oversight is expanding. Massachusetts H.5159 introduced post-transaction monitoring for up to five years; New Jersey expanded assessment exposure in 2025 and removed the one-room exemption for 2026. Both belong in transaction diligence.
• Need-review thresholds move. Vermont raised thresholds in 2025, New York has proposed raising ASC and clinic capital thresholds from $6 million to $8 million, and Maine indexes thresholds annually. Verify thresholds in the year of the project, not from a prior file.

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Series Roadmap

Volume	Jurisdictions	Status
Volume 1 — Northeast and Mid-Atlantic	Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont	Published
Volume 2 — South and Southeast	Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, West Virginia	In development

Volume	Jurisdictions	Status
Volume 3 — Midwest and Great Plains	Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin	In development
Volume 4 — West, Southwest, and Non-Contiguous	Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oklahoma, Oregon, Texas, Utah, Washington, Wyoming	In development

GoHealthcare Insight

Volumes 2 through 4 will follow the same profile structure and the same verification standard. Volume 3 and Volume 4 carry the highest concentration of Medicare prior authorization program exposure — Ohio, Oklahoma, Texas, Arizona, and Washington are WISeR states; Arizona, Ohio, and Texas are also ASC Prior Authorization Demonstration Phase 2 states; and California, Florida, Georgia, and Tennessee are Phase 1 states. Organizations operating in those markets should treat the remaining volumes as sequenced by their own footprint rather than by publication order.

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Key Takeaways

• Twelve jurisdictions, twelve different definitions of what makes a facility an ambulatory surgical facility. The federal Conditions for Coverage are the floor, not the framework.
• Maryland's two-operating-room line and Pennsylvania's Class A pathway are the two structural thresholds in this region with the largest effect on development cost and timeline.
• Accreditation is a condition of licensure in several of these states, on defined clocks measured from initial licensure or approval.
• New Jersey's assessment framework changed materially in 2025 and again for 2026, and a pending bill would restructure surgical practice oversight entirely.
• Massachusetts licenses ambulatory surgery within the clinic framework and now imposes post-transaction monitoring for up to five years.
• Need-review thresholds in this region are actively moving. Verify in the project year.
• Every citation here is a starting point for primary research and counsel review, not a substitute for it.

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References

All references are primary or authoritative secondary sources. Blogs, AI-generated content, marketing websites, and non-authoritative sources are excluded by standard. Complete website addresses are provided.

1. National Academy for State Health Policy. 50-State Scan of State Certificate-of-Need Programs, database updated December 12, 2025. Website: https://nashp.org/state-tracker/50-state-scan-of-state-certificate-of-need-programs/
2. Centers for Medicare & Medicaid Services. Prior Authorization Demonstration for Certain Ambulatory Surgical Center (ASC) Services. Website: https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-pre-claim-review-initiatives/prior-authorization-demonstration-certain-ambulatory-surgical-center-services
3. Centers for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation. WISeR Model Provider and Supplier Operational Guide. Website: https://www.cms.gov/priorities/innovation/files/wiser-provider-supplier-guide.pdf
4. Electronic Code of Federal Regulations. 42 CFR Part 416, Subpart C — Specific Conditions for Coverage for Ambulatory Surgical Services. Website: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-416/subpart-C
5. Connecticut General Assembly. Conn. Gen. Stat. § 19a-493b — Outpatient surgical facilities: definition, licensure and exceptions, certificate of need, waiver. Website: https://law.justia.com/codes/connecticut/title-19a/chapter-368v/section-19a-493b
6. Connecticut General Assembly. Conn. Gen. Stat. § 19a-491 — License and certificate required. Website: https://law.justia.com/codes/connecticut/2019/title-19a/chapter-368v/section-19a-491/
7. Delaware Department of Health and Social Services, Division of Health Care Quality. 16 DE Admin. Code 4405, Free Standing Surgical Centers — final order, Delaware Register of Regulations, December 1, 2021. Website: https://archive.regulations.delaware.gov/register/december2021/final/25%20DE%20Reg%20627%2012-01-21.pdf
8. Delaware Code. 24 Del. C. § 1705 — Accreditation of facilities where office-based surgeries are performed. Website: https://delcode.delaware.gov/title24/c017/sc01/
9. Council of the District of Columbia. D.C. Law 2-66, D.C. Ambulatory Surgical Treatment Center Licensure Act. Website: https://code.dccouncil.gov/us/dc/council/laws/2-66
10. DC Health. Health Care Facilities. Website: https://dchealth.dc.gov/service/health-care-facilities
11. Maine Department of Health and Human Services, Division of Licensing and Certification. Medical Facilities — Ambulatory Surgical Centers; 10-144 CMR Chapter 125, Regulations Governing the Licensing of Ambulatory Surgical Facilities. Website: https://www.maine.gov/dhhs/dlc/licensing-certification/medical-facilities
12. Maine Department of Health and Human Services. Healthcare Oversight — Certificate of Need, 22 M.R.S.A. Chapter 103-A. Website: https://www.maine.gov/dhhs/dlc/healthcare-oversight
13. Maine Department of Health and Human Services. Sentinel Events — 22 M.R.S.A. § 8753 and 10-144 CMR Ch. 114. Website: https://www.maine.gov/dhhs/dlc/safety-reporting/sentinel-events
14. Maryland Department of Health, Office of Health Care Quality. Freestanding Ambulatory Surgical Centers — COMAR
15. 05.01 and 10.05.05. Website: https://health.maryland.gov/ohcq/Pages/Freestanding-Ambulatory-Surgical-Centers.aspx

15. Maryland Health Care Commission. Ambulatory Surgery — Determination of Coverage and Certificate of Need. Website: https://mhcc.maryland.gov/healthcare-communities/state-health-planning-and-certificate-need-con/ambulatory-surgery
16. Code of Maryland Regulations. COMAR 10.24.01.05 — Ambulatory Surgical Facilities: Determination of Coverage and Data Reporting. Website: http://mdrules.elaws.us/comar/10.24.01.05
17. Commonwealth of Massachusetts. 105 CMR 140.000, Licensure of Clinics. Website: https://www.mass.gov/regulations/105-CMR-14000-licensure-of-clinics
18. Code of Massachusetts Regulations. 105 CMR 100.730 — Determination of Need for Original Licensure. Website: https://regulations.justia.com/states/massachusetts/105-cmr/title-105-cmr-100-000/section-100-730
19. Commonwealth of Massachusetts. Health care facility licensure regulations. Website: https://www.mass.gov/lists/health-care-facility-licensure-regulations
20. McDermott Will & Emery. Massachusetts H.5159 includes new licensing requirements. Website: https://www.mwe.com/insights/mass-h-5159-includes-new-licensing-requirements/
21. New Hampshire Department of Health and Human Services. He-P 812, Ambulatory Surgical Centers. Website: https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/inline-documents/sonh/he-p812-ambulatory-surgical-centers.pdf
22. New Jersey Department of Health. Health Facilities — Statutes, Rules and Rule Proposals, including N.J.A.C. 8:43A and N.J.A.C. 8:33. Website: https://www.nj.gov/health/healthfacilities/rules.shtml
23. New Jersey Revised Statutes § 26:2H-12 — Operation, requirements for certain health care facilities; application for license; fee. Website: https://law.justia.com/codes/new-jersey/title-26/section-26-2h-12/
24. New Jersey Legislature. P.L. 2025, c.70 (A5809). Website: https://pub.njleg.gov/Bills/2024/PL25/70_.HTM
25. New York Codes, Rules and Regulations. 10 NYCRR Part 755 — Free-standing and Off-site Hospital Based Ambulatory Surgery Services. Website: https://regulations.justia.com/states/new-york/title-10/chapter-v/subchapter-c/article-6/part-755
26. New York Codes, Rules and Regulations. 10 NYCRR § 709.5 — Ambulatory surgery services (need methodology). Website: https://www.law.cornell.edu/regulations/new-york/10-NYCRR-709.5
27. New York State Department of Health. Office-Based Surgery Frequently Asked Questions for Practitioners. Website: https://www.health.ny.gov/professionals/office-based_surgery/obs_faq.htm
28. Pennsylvania Code. 28 Pa. Code Chapter 551 — General Information (Ambulatory Surgical Facilities), including § 551.31 Licensure. Website: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter551/chap551toc.html&d=reduce
29. Pennsylvania Code. Title 28, Part IV, Subpart F — Ambulatory Surgical Facilities, Chapters 551—571. Website: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter551/chap551toc.html

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30. Rhode Island Department of State. 216-RICR-40-10-5, Licensing of Freestanding Ambulatory Surgical Centers. Website: https://rules.sos.ri.gov/regulations/part/216-40-10-5
31. Rhode Island Department of State. 216-RICR-40-10-13, Licensure of Physician Ambulatory Surgery Centers and Podiatry Ambulatory Surgery Centers. Website: https://rules.sos.ri.gov/regulations/part/216-40-10-13
32. Rhode Island Department of Health. Freestanding Ambulatory Surgical Centers. Website: https://health.ri.gov/freestanding-ambulatory-surgical-centers
33. Rhode Island General Laws Chapter 23-17 — Licensing of Healthcare Facilities. Website: https://law.justia.com/codes/rhode-island/title-23/chapter-23-17/
34. Green Mountain Care Board. Certificate of Need — 18 V.S.A. Chapter 221; Act 15 of 2025 thresholds. Website: https://gmcboard.vermont.gov/certificate-need
35. Vermont Statutes. 18 V.S.A. § 9432 — Definitions, including ambulatory surgical center. Website: https://legislature.vermont.gov/statutes/section/18/221/09432
36. Holland & Knight. A Review of Recent State and Federal Changes to the Ambulatory Surgical Center Regulatory Landscape. Website: https://www.hklaw.com/en/insights/publications/2025/10/a-review-of-recent-state-and-federal-changes-to-the-ambulatory
37. GoHealthcare Practice Solutions Knowledge Center. Website: https://www.gohealthcarellc.com

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Related GoHealthcare Resources

• ASC Specialty Hub — the other twelve pages listed in the Page Index at the front of this document, available in the GoHealthcare Knowledge Center at https://www.gohealthcarellc.com
• GoHealthcare MSK Specialty Procedure Library™ — procedure-specific operational guides across interventional pain, spine surgery, neuromodulation, orthopedic surgery, and peripheral nerve procedures.
• GoHealthcare Revenue Cycle Knowledge Center — detailed reimbursement methodology, fee schedule analysis, payment rate modeling, edit tables, and revenue cycle analytics, which are intentionally outside the scope of the Procedure Library.

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Document History

Version	Date	Summary of changes	Prepared by
1.0	August 3, 2026	Initial publication. Volume 1 of the four-volume ASC State Regulatory Profiles series. Provides citation-level profiles for twelve Northeast and Mid-Atlantic jurisdictions covering licensing authority and statutory grant, licensure regulation, facility categories and definitional thresholds, need review regime and ambulatory surgery applicability, accreditation interaction, notable operational requirements, Medicare prior authorization program participation, and identified state utilization review enactments; includes a comparative summary table, regional operating observations, and the series roadmap for Volumes 2 through 4.	GoHealthcare Practice Solutions, under the leadership of Pinky Maniri, Founder and Chief Executive Officer

On Document Currency

This page carries a Publication Date and a Document Version rather than a scheduled review date. GoHealthcare's editorial standard is that a published review date becomes a public commitment the moment it lapses. Currency is communicated through version releases and through the verification standards stated throughout this document.

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Educational Disclaimer and Terms of Use

This document is published by GoHealthcare Practice Solutions, under the leadership of Pinky Maniri, Founder and Chief Executive Officer. The following terms govern its use.

1. Purpose and limitation of purpose. This document is provided solely for educational and operational reference purposes. It is intended to help healthcare professionals understand the operational, documentation, payer, coding, compliance, and reimbursement environment surrounding ambulatory surgical center services. It is not a clinical practice guideline, a procedural technique manual, a physician training resource, an accreditation manual, or a substitute for the specialty society guidance, clinical textbooks, and procedural training on which clinical practice properly depends.
2. No professional relationship. Use of this document does not create a physician-patient relationship, an attorney-client relationship, a consulting engagement, or any other professional relationship between the reader and GoHealthcare Practice Solutions or any of its personnel. No confidential relationship is formed by reading, downloading, distributing, or relying upon this document.
3. Not medical advice. Nothing in this document constitutes medical advice or a recommendation regarding the care of any individual patient. All clinical decisions, including patient selection, site-of-service determination, procedure selection, and discharge, remain the exclusive responsibility of the treating physician exercising independent clinical judgment in the context of the individual patient's circumstances.
4. Not legal advice. Nothing in this document constitutes legal advice or an opinion on the lawfulness of any arrangement, structure, policy, billing practice, or course of conduct. Matters involving the Anti-Kickback Statute, the Physician Self-Referral Law (Stark), the False Claims Act, the Civil Monetary Penalties Law, state fraud and abuse law, state licensure and certificate of need requirements, corporate practice of medicine, ownership and investment structures, contracting, employment, and privacy should be reviewed by qualified healthcare counsel before implementation.
5. Coding limitations and compliance responsibility. Coding content in this document is a general operational orientation only. It does not constitute coding advice, certification, or a guarantee of payment. Code selection, modifier application, and claim submission are the responsibility of the submitting entity. Inaccurate or unsupported claim submission may carry consequences under the False Claims Act, the Civil Monetary Penalties Law, the Anti-Kickback Statute, and the Physician Self-Referral Law, among other authorities. All coding must be supported by the medical record and verified against current official code descriptors and the applicable payer's current policy.
6. No guarantee of coverage, payment, or authorization outcome. Nothing in this document guarantees that any payer will authorize any service, cover any procedure, or pay any claim. Coverage determinations, authorization decisions, and payment outcomes rest with the applicable payer under its own policies and the governing contract.
7. Currency limitations. Coverage policies, national and local coverage determinations, payment rates, conversion factors, covered procedures lists, quality reporting requirements, correct coding edits, utilization management criteria, demonstration and model parameters, state statutes and regulations, and applicable law change frequently and often without broad notice. Information in this document reflects sources available as of the Publication Date and may become inaccurate at any time thereafter. Every material fact should be independently verified against the current primary source before reliance.
8. Payer content and artificial intelligence processing. Summaries of payer coverage policies and utilization management criteria in this document are original synthesis prepared for educational purposes and are not reproductions of payer manuals or proprietary criteria sets. Payer clinical policy content may be subject to use restrictions, including restrictions on reproduction, redistribution, and ingestion into artificial intelligence systems. Readers who intend to process payer-derived content through artificial intelligence systems should confirm the applicable license terms and obtain legal review before doing so.
9. Artificial intelligence-assisted authorship disclosure. Research synthesis, drafting, and production of this document were assisted by artificial intelligence tools under human editorial direction. All substantive content was reviewed by GoHealthcare Practice Solutions. Codes, coverage citations, regulatory references, effective dates, and payment figures were verified against primary sources during preparation. Notwithstanding that verification, readers must independently confirm all information before operational, billing, contracting, clinical, or compliance reliance.
10. Prohibition on use for artificial intelligence model training. This document may not be used, in whole or in part, to train, fine-tune, evaluate, or otherwise develop any artificial intelligence or machine learning model, nor incorporated into any dataset, corpus, retrieval index, or embedding store used for such purposes, without the express prior written permission of GoHealthcare Practice Solutions.
11. Intellectual property and permitted use. This document and the GoHealthcare MSK Specialty Procedure Library™ are the property of GoHealthcare Practice Solutions. It may be read, printed, and shared internally within a healthcare organization for educational purposes with attribution intact. It may not be modified, resold, republished, incorporated into a commercial product, or presented as the work of another party.
12. Third-party trademarks. CPT® is a registered trademark of the American Medical Association. All other product names, brand names, company names, and trademarks referenced are the property of their respective owners. Reference to any organization, payer, utilization management entity, device manufacturer, accreditation body, or product is for identification and educational purposes only and does not imply endorsement, affiliation, sponsorship, or any relationship between that party and GoHealthcare Practice Solutions.
13. External websites. Website addresses are provided for reader convenience. GoHealthcare Practice Solutions does not control third-party websites and is not responsible for their content, availability, accuracy, or continued existence. Inclusion of a website address does not constitute endorsement.
14. Limitation of liability. To the fullest extent permitted by law, GoHealthcare Practice Solutions and its personnel disclaim all liability for any loss, damage, claim, penalty, denial, recoupment, or adverse outcome arising from use of, or reliance upon, this document. Use is entirely at the reader's own risk and professional discretion.
15. Corrections and contact. GoHealthcare Practice Solutions welcomes correction. If you identify an error, an outdated citation, or a coverage position that has changed, please contact GoHealthcare Practice Solutions through https://www.gohealthcarellc.com so that it can be evaluated and, where warranted, corrected in a subsequent version and reflected in the Document History.

Educational Disclaimer — Summary

This document was developed by GoHealthcare Practice Solutions, under the leadership of Pinky Maniri, Founder and Chief Executive Officer — MSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance.

It is educational and operational reference material only. It does not replace physician clinical judgment, payer policy review, legal advice, accreditation standards, or official CMS guidance. Coverage policies, coding guidance, and reimbursement requirements must always be verified with the applicable payer and current regulatory sources.

GoHealthcare Practice Solutions — a national Musculoskeletal Specialty Management Services Organization. Website: https://www.gohealthcarellc.com

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