ASC SPECIALTY HUB — PAGE 13 OF 13
Developed by GoHealthcare Practice Solutions
ASC State Regulatory Reference
Certificate of Need, Medicare Program Participation, AI and Prior Authorization Law, and a State Requirement Research Protocol
State law determines whether an ASC may be built, what it may do, and how quickly commercial payers must answer. This page provides a fifty-one jurisdiction comparative table across certificate of need status, Medicare prior authorization program participation, and state AI and prior authorization legislation — together with a structured research protocol for building a verified State Requirement Profile in each jurisdiction.
Publication Information
Document Control
| Document Title | ASC State Regulatory Reference — Certificate of Need, Medicare Program Participation, AI and Prior Authorization Law, and a State Requirement Research Protocol |
|---|---|
| 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 | Orient ASC leaders to the state regulatory layer and provide a disciplined protocol for verifying state-specific requirements, rather than substituting for primary state legal research. |
|---|---|
| Primary Audience | Physicians; advanced practice providers; ASC administrators and nurse leaders; prior authorization specialists; utilization management teams; revenue cycle and coding professionals; clinical documentation specialists; case managers; workers' compensation professionals; attorneys; healthcare executives |
| Credentials | MSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance |
| Primary Sources | CMS CY 2026 OPPS/ASC Final Rule (CMS-1834-FC); 42 CFR Part 416, Subpart C; Medicare Claims Processing Manual Chapter 14; CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F); CMS Prior Authorization Demonstration for Certain ASC Services; CMS WISeR Model Provider and Supplier Operational Guide; ASCQR Program specifications; CMS State Operations Manual Appendix L and Exhibit 351; AMA CPT®; ICD-10-CM FY2026; commercial payer and delegated utilization management clinical policies; state statutes and enactments through mid-2026 |
| Scope Exclusions | This page does not tabulate state licensure requirements, physical plant standards, staffing ratios, or scope-of-service limits, because available cross-state compilations of those items are materially out of date. It also does not state whether a given state's certificate of need program applies to ambulatory surgery centers, which must be confirmed with the state. It is not legal advice and is not a substitute for primary state legal research. |
| Website | https://www.gohealthcarellc.com |
ASC Specialty Hub
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 |
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ASC Specialty Hub
Why the State Layer Matters
Everything in the other twelve pages of this Hub describes a federal framework. That framework is only half of the operating environment. State law determines whether an ambulatory surgery center may be built at all, whether it must be licensed and by whom, what procedures it may perform, what physical plant and staffing standards apply, what transfer arrangements are required, how physician ownership must be disclosed, how quickly commercial payers must decide authorization requests, whether a gold card exemption exists, and whether an insurer may use artificial intelligence in a medical necessity denial.
For a single-site center this is a one-time research exercise with an annual refresh. For a multi-state organization it is a standing operational discipline, because the same authorization workflow will be governed by different decision timelines, different reviewer qualification requirements, and different AI restrictions in each jurisdiction.
What This Page Does and Does Not Do
This page is a research framework and a comparative orientation. It is not a substitute for primary state legal research, and it deliberately does not tabulate state licensure requirements, physical plant standards, staffing ratios, or scope-of-service limits.
That omission is intentional. The available cross-state compilations of ASC licensure requirements are materially out of date, and certificate of need program existence is not the same question as certificate of need applicability to ambulatory surgery centers — several states maintain a CON program that excludes or has been amended to exclude ASCs. Publishing a state-by-state licensure table sourced from stale secondary compilations would create exactly the kind of confident, unverifiable detail that this Library's verification standard exists to prevent.
Use the comparative table in Section 3 for orientation and the research protocol in Section 4 to build a verified State Requirement Profile for each jurisdiction in which your organization operates. Confirm every item with the state agency and with qualified healthcare counsel before committing capital or scheduling cases.
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ASC Specialty Hub
The Four State Dimensions Tracked in This Page
| Dimension | What is tracked | Source and currency |
|---|---|---|
| Certificate of need | Whether the jurisdiction maintains a CON program | National Academy for State Health Policy 50-state scan of state certificate-of-need programs, database updated December 12, 2025. Program existence only — ASC applicability must be confirmed with the state. |
| Medicare prior authorization programs | Whether the state participates in the CMS ASC Prior Authorization Demonstration, the WISeR Model, or both | CMS program pages and operational guides. Both programs are multi-year and parameters are revised by version. |
| AI in utilization review | Whether the state has enacted legislation governing insurer use of artificial intelligence in prior authorization and medical necessity determinations | State enactments through mid-2026. This area is moving faster than any published compilation can track. |
| Prior authorization reform | Decision timeline statutes, gold carding statutes, continuity-of-authorization provisions, and service-specific exemptions | State enactments through mid-2026. Applies to state-regulated plans; self-funded ERISA plans are generally outside state insurance regulation. |
Which Plans State Law Actually Reaches
State insurance law generally reaches fully insured, state-regulated plans. It generally does not reach self-funded employer plans governed by ERISA, and it does not reach Medicare fee-for-service. A gold card statute or a decision timeline statute therefore applies to a subset of a typical ASC's commercial volume. Determine plan funding status before relying on a state protection.
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ASC Specialty Hub
State-by-State Comparative Table
CON column reflects whether the jurisdiction maintains a certificate of need program, not whether that program applies to ambulatory surgery centers. Medicare PA column identifies participation in the CMS ASC Prior Authorization Demonstration (Phase 1 or Phase 2) and the WISeR Model. Notes summarize selected verified enactments and are not a complete statement of any state's law.
| State | CO N | Medicare PA program | Selected prior authorization, AI, and ASC regulatory notes |
|---|---|---|---|
| Alabama | Yes | -- | AI in utilization review: SB 63, signed April 2026, effective October 1, 2026 — licensed professional must make any medical necessity denial; annual certification and written disclosure required. |
| Alaska | Yes | -- | Prior authorization timelines effective 2026 — among the fastest enacted, with decisions required within 72 hours for routine and 24 hours for expedited requests. |
| Arizona | No | WISeR + ASC Demo P2 | WISeR Model state and ASC Prior Authorization Demonstration Phase 2 state — two distinct Medicare prior authorization programs apply. AI utilization review legislation enacted. |
| Arkansas | Yes | -- | Gold carding program amended in 2025 to refine evaluation periods and eligibility criteria. |
| California | No | ASC Demo P1 | ASC Prior Authorization Demonstration Phase 1 state. SB 1120 governs AI in utilization review — decisions must rest on individual clinical history. SB 598 imposes tighter decision timelines than the federal baseline. |
| Colorado | No | -- | HB 1139 governs AI in utilization review across insurers, pharmacy benefit managers, and utilization review organizations — individualized clinical basis, non-discrimination, and periodic audit. Gold carding legislation active. |
| Connecticut | Yes | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| Delaware | Yes | -- | Prior authorization decision timeline legislation enacted. |
| Florida | Yes | ASC Demo P1 | ASC Prior Authorization Demonstration Phase 1 state. |
| Georgia | Yes | ASC Demo P1 | ASC Prior Authorization Demonstration Phase 1 state. SB 444, effective January 1, 2027 — AI may not issue an adverse determination until a natural person conducts review with clinical peer participation. Recent CON reform affecting ASC development. |
| Hawaii | Yes | -- | ASC exemption from the CON process has been the subject of active legislative debate. |
| Idaho | No | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| Illinois | Yes | -- | Prior authorization reporting requirements; prior authorization prohibited for inpatient psychiatric admission and outpatient mental health services as of January 1. |
| Indiana | Yes | -- | Prior authorization decision timeline legislation enacted. AI in healthcare legislation enacted March 2026. |
| Iowa | Yes | -- | Prior authorization decision timeline legislation enacted. Iowa Code § 514F.8(2A), effective July 1, 2026 — AI may perform initial review but may not issue a medical necessity denial. Recent ASC-related regulatory activity. |
| Kansas | No | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| Kentucky | Yes | -- | Prior authorization exemption legislation under consideration. |
| State | CO N | Medicare PA program | Selected prior authorization, AI, and ASC regulatory notes |
|---|---|---|---|
| Louisiana | No | -- | Gold carding statute active. AI utilization review legislation proposed, including a prohibition on using AI in the subsequent review of an AI-influenced denial. |
| Maine | Yes | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| Maryland | Yes | ASC Demo P1 | ASC Prior Authorization Demonstration Phase 1 state. AI utilization review legislation enacted. |
| Massachusetts | Yes | -- | Broadened healthcare transaction reporting and post-transaction monitoring obligations reaching ASCs; CON program under active criticism regarding access. |
| Michigan | Yes | -- | Gold carding statute active. |
| Minnesota | Yes | -- | CON program is limited in scope relative to most CON states. |
| Mississippi | Yes | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| Missouri | Yes | -- | Prior authorization reduction legislation proposed. |
| Montana | Yes | -- | CON law was substantially repealed in 2021; reported growth in ASCs, home health agencies, and treatment centers since. Confirm current ASC applicability directly with the state. |
| Nebraska | Yes | -- | Prior authorization decision timeline legislation effective at the start of 2026. LB 77 requires disclosure of AI use to providers and enrollees. |
| Nevada | Yes | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| New Hampshire | No | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| New Jersey | Yes | WISeR | WISeR Model state. S1255 requires payers to honor prior authorization approvals for the duration of the treatment course. Recent legislative activity affecting ASC assessments and licensure. |
| New Mexico | No | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| New York | Yes | ASC Demo P1 | ASC Prior Authorization Demonstration Phase 1 state. Proposed increases to CON capital expenditure thresholds. |
| North Carolina | Yes | -- | Recent CON revision activity affecting ASC development. |
| North Dakota | No | -- | Prior authorization decision timeline legislation effective at the start of 2026. |
| Ohio | Yes | WISeR + ASC Demo P2 | WISeR Model state and ASC Prior Authorization Demonstration Phase 2 state — two distinct Medicare prior authorization programs apply. |
| Oklahoma | Yes | WISeR | WISeR Model state. Prior authorization decision timeline legislation enacted. |
| Oregon | Yes | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| Pennsylvania | No | ASC Demo P1 | ASC Prior Authorization Demonstration Phase 1 state. |
| Rhode Island | Yes | -- | Prior authorization eliminated for routine primary care services ordered by a primary care physician under a three-year pilot beginning October 1, 2025. |
| South Carolina | Yes | -- | CON requirement for ASCs eliminated by legislation; the state CON program continues for other facility types. |
| South Dakota | No | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| Tennessee | Yes | ASC Demo P1 | ASC Prior Authorization Demonstration Phase 1 state. CON requirement for ASCs repealed, with non-hospital-affiliated ASCs required to participate in TennCare and provide a comparable level of care to enrollees and charity cases. |
| State | CO N | Medicare PA program | Selected prior authorization, AI, and ASC regulatory notes |
|---|---|---|---|
| Texas | No | WISeR + ASC Demo P2 | WISeR Model state and ASC Prior Authorization Demonstration Phase 2 state — two distinct Medicare prior authorization programs apply. HB 3459 gold card law waives prior authorization for providers meeting a 90 percent approval rate for a service. SB 815 prohibits AI as the sole basis for an adverse determination. |
| Utah | No | -- | Prior authorization reform enacted — 72 hours urgent, seven calendar days non-urgent, with authorizations for chronic conditions valid for 12 months. AI disclosure requirements and a regulatory sandbox program. |
| Vermont | Yes | -- | Gold carding statute active. |
| Virginia | Yes | -- | Prior authorization reform legislation enacted in 2026. |
| Washington | Yes | WISeR | WISeR Model state. SB 5395, effective June 11, 2026 — among the most comprehensive state limits on AI in prior authorization, requiring a licensed physician or health professional for medical necessity denials and individualized clinical review. |
| Washington, D.C. | Yes | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
| West Virginia | Yes | -- | Gold carding statute active. |
| Wisconsin | No | -- | No state licensure or certificate requirement for ASCs; Medicare certification proceeds through the MAC and an accrediting organization or state survey. |
| Wyoming | No | -- | No enactment identified in the dimensions tracked here. Verify licensure and scope requirements directly with the state. |
The Three-State Overlap
Arizona, Ohio, and Texas are the only three states subject to both the CMS ASC Prior Authorization Demonstration and the WISeR Model. Centers in those states operate under two distinct Medicare prior authorization regimes with different service lists, different submission channels, and different review entities. A single screening step that checks both lists at scheduling is the practical control.
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ASC Specialty Hub
Building a State Requirement Profile
The protocol below is what GoHealthcare uses to construct a verified state requirement profile for a jurisdiction. It should be completed before a center is developed, refreshed annually, and refreshed on notice of legislative change. Each item should record the citation, the responsible agency, the verification date, and the person who verified it.
A. Facility Authorization to Operate
- Does the state license ambulatory surgery centers, and under what statutory and regulatory citation?
- Which agency licenses — department of health, health facilities division, medical board, or another authority?
- Is a certificate of need required for a new ASC, for adding operating rooms, for adding a specialty, or for a capital expenditure above a threshold? What is the current threshold?
- Are there conditions attached to CON exemption or repeal — for example, Medicaid participation or charity care obligations?
- Does the state accept accreditation in lieu of, or in coordination with, a state licensure survey?
- Is there a moratorium, a needs-based formula, or a competitor challenge process?
- What are the change-of-ownership, transaction reporting, and post-transaction monitoring obligations?
- Are there state limits on the procedures an ASC may perform, or on anesthesia class, that are narrower than the Medicare covered procedures list?
- Are there state-specific limits on length of stay, overnight recovery, or extended recovery beds — and do they differ from the federal 24-hour expectation?
- What physical plant, operating room, ventilation, and life safety standards apply, and which edition of which code has the state adopted?
- Are there state-mandated nurse staffing, credentialing, or supervision requirements beyond the Conditions for Coverage?
- Is a written transfer agreement required, or are admitting privileges accepted as an alternative? Is there a distance requirement to the receiving hospital?
- Are there state-specific adverse event, sentinel event, or infection reporting obligations, and on what timeline?
- Are there state requirements for pediatric patients, malignant hyperthermia preparedness, or specific emergency equipment?
C. Ownership, Referral, and Business Structure
- Does the state have a self-referral statute broader than the federal Physician Self-Referral Law, and does it reach ASCs?
- Is there a state anti-kickback or fee-splitting statute with requirements beyond federal law?
- Does the corporate practice of medicine doctrine apply, and how does it affect management company and investor structures?
- What physician financial interest disclosure is required, in what form, and at what point before the procedure?
- Are there state restrictions on non-compete provisions, physician employment, or management fee structures relevant to the center's arrangements?
- Are there transaction notice, review, or approval requirements for private equity or health system investment?
D. Payer, Utilization Review, and Transparency Law
- What decision timelines does state law impose on state-regulated plans for expedited and standard prior authorization requests?
- Is there a gold carding statute, and what is the qualifying threshold, look-back period, and exemption duration?
- Does state law require a same-specialty or clinical peer reviewer for adverse determinations?
- Does state law restrict insurer use of artificial intelligence in utilization review, and what specifically does it require — human decision-maker, individualized clinical basis, disclosure, audit, certification?
- How long must an approved authorization remain valid, and does it survive a plan change, network change, or course of treatment?
- What is the state external review process, and what are the filing deadlines?
- Does the state have a workers' compensation medical fee schedule covering ASC facility services, and what is its basis?
- How does state Medicaid cover and pay ASC facility services, and is authorization delegated to a vendor?
- What state price transparency, balance billing, and consumer notice obligations apply in addition to federal requirements?
E. Provider-Side Artificial Intelligence
- Does the state require disclosure to patients when artificial intelligence is used in their care or documentation?
- Are there state restrictions on autonomous clinical decision-making by AI systems?
- Are there state data privacy requirements beyond HIPAA affecting AI vendor arrangements?
- Does the state operate a regulatory sandbox or notification program for healthcare AI deployment?
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ASC Specialty Hub
Multi-State Operating Considerations
| Challenge | Practical response |
|---|---|
| Different decision timelines by state | Configure authorization follow-up cadence by state and plan type rather than applying a single national escalation schedule |
| Different gold card thresholds and mechanics | Track physician approval rates by payer and by state against the specific statutory or program threshold, not a generic 90 percent assumption |
| Different AI restrictions on payers | Capture reviewer name, credential, and decision timestamp on every adverse determination in every state; the record is only useful if it is routine |
| Different CON and licensure regimes | Maintain a State Requirement Profile per jurisdiction with citation, agency, verification date, and verifier |
| Different scope-of-service limits | Screen the case list against state scope limits as well as against the payer covered procedures list |
| Different transfer agreement requirements | Verify agreement currency annually per site, not per organization |
| Overlapping Medicare programs | Single screening step at scheduling that checks both the ASC demonstration categories and the WISeR list where applicable |
| Different workers' compensation fee schedules | Model each state's schedule separately in the expected-reimbursement engine; workers' compensation is frequently the least-modeled and most-underpaid payer class in an MSK ASC |
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ASC Specialty Hub
Key Takeaways
- State law determines whether an ASC can exist, what it may do, and how quickly commercial payers must answer. The federal framework is only half the operating environment.
- Certificate of need program existence is not the same as certificate of need applicability to ASCs. Several states maintain a program that excludes or has been amended to exclude ambulatory surgery centers.
- Arizona, Ohio, and Texas are subject to both Medicare prior authorization programs reaching ASCs.
- State AI utilization review laws consistently require a licensed human decision-maker and an individualized clinical basis for adverse determinations. That is an appeal lever — but only with reviewer identity and timestamps captured routinely.
- State insurance law generally does not reach self-funded ERISA plans or Medicare fee-for-service. Determine plan funding status before relying on a state protection.
- Build and maintain a verified State Requirement Profile for every jurisdiction, with citation, agency, verification date, and verifier. Refresh annually and on legislative change.
- This page is a framework, not a legal compilation. Verify every item with the state agency and with qualified healthcare counsel.
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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.
- 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/
- 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
- Centers for Medicare & Medicaid Services. Prior Authorization Demonstration for Certain Ambulatory Surgical Center Services — Frequently Asked Questions, December 23, 2025. Website: https://www.cms.gov/files/document/asc-demonstration-faqs.pdf
- 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
- Centers for Medicare & Medicaid Services. WISeR Model Frequently Asked Questions. Website: https://www.cms.gov/priorities/innovation/files/document/wiser-model-frequently-asked-questions
- Holland & Knight. States Continue Efforts to Regulate AI in Healthcare: A Review of Legislation Passed in 2026. Website: https://www.hklaw.com/en/insights/publications/2026/05/states-continue-efforts-to-regulate-ai-in-healthcare
- KFF. Regulation of AI in Prior Authorization and Claims Review: A Look at Federal and State Consumer Protections. Website: https://www.kff.org/patient-consumer-protections/regulation-of-ai-in-prior-authorization-and-claims-review-a-look-at-federal-and-state-consumer-protections/
- Georgetown University Center on Health Insurance Reforms. Prior Authorization Reform Heats Up. Website: https://chir.georgetown.edu/prior-authorization-reform-heats-up/
- 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
- Centers for Medicare & Medicaid Services. CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), Fact Sheet. Website: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f
- 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
- Ambulatory Surgery Center Association. Website: https://www.ascassociation.org
- GoHealthcare Practice Solutions Knowledge Center. Website: https://www.gohealthcarellc.com
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ASC Specialty Hub
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. Establishes the four state dimensions tracked, a fifty-one jurisdiction comparative table of certificate of need program status (per the National Academy for State Health Policy database updated December 12, 2025), CMS ASC Prior Authorization Demonstration and WISeR Model participation, and selected verified state AI and prior authorization enactments through mid-2026; identifies the Arizona, Ohio, and Texas overlap between both Medicare programs; and provides a five-part State Requirement Profile research protocol. | 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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ASC Specialty Hub
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
Back to page navigation ↑Strengthen Ambulatory Surgery Center Operations Across the Entire Episode
GoHealthcare Practice Solutions supports ambulatory surgery centers and musculoskeletal organizations across patient access, prior authorization, clinical documentation, coding alignment, denial prevention, revenue cycle management, compliance, performance analytics, and healthcare AI governance.
Developed by
Pinky Maniri
MSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance
Founder and Chief Executive Officer, GoHealthcare Practice Solutions