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016.06.3-216.300. Sterilizations

AR ADC 016.06.3-216.300Arkansas Administrative Code

West's Arkansas Administrative Code
Title 016. Department of Human Services
Division 06. Division of Medical Services
Rule 3. Ambulatory Surgical Center Provider Manual (Refs & Annos)
Section 210.000. Program Coverage
Ark. Admin. Code 016.06.3-216.300
016.06.3-216.300. Sterilizations
Currentness
Non-therapeutic sterilization means any procedure or operation for which the primary purpose is to render an individual permanently incapable of reproducing and which is not either (1) a necessary part of the treatment of an existing illness or injury or (2) medically indicated as an accompaniment of an operation of the female genitourinary tract. The reason for which the individual decides to take permanent and irreversible action is irrelevant. It may be for social, economic or psychological reasons or because a pregnancy would be inadvisable for medical reasons.
Prior authorization is not required for sterilization. However, all applicable criteria described in this manual must be met.
Only the official sterilization consent form (DMS-615) may be used for compliance with the documentation requirements. View or print form DMS-615. An original or copy of the completed form must be submitted with each claim, and a copy must be maintained with the patient’s medical records for a minimum of five (5) years.
Medicaid covers sterilization only when the following conditions are met:
A. The person on whom the sterilization procedure is to be performed voluntarily requests such services.
B. The person is mentally and legally competent to give informed consent.
C. The person is 21 years of age or older at the time informed consent is obtained.
D. The person to be sterilized shall not be an institutionalized individual. The regulations define “institutionalized individual” as a person who is (1) involuntarily confined or detained, under a civil or criminal statute in a correctional or rehabilitative facility including those for a mental illness, or (2) confined under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness.
E. The person has been counseled, both orally and in writing, concerning the effect and impact of sterilization and alternative methods of birth control.
F. Such informed consent and counseling are properly documented and submitted with the claim from each provider.
G. Informed consent may not be obtained while the person to be sterilized is:
1. In labor or during childbirth,
2. Seeking to obtain or obtaining an abortion or
3. Under the influence of alcohol or other substances that affect the individual’s state of awareness.
H. Such sterilization is performed at least 30 days, but not more than 180 days, after the date of informed consent. The following are exceptions to the 30-day waiting period:
1. In the case of premature delivery, provided at least 72 hours have passed between giving the informed consent and performance of the sterilization procedure, and counseling and informed consent was given at least 30 days before the expected date of delivery and
2. In the case of emergency abdominal surgery, provided at least 72 hours have passed between giving of informed consent and the performance of the sterilization procedure.
NOTE: Either of these exceptions to the 30-day waiting period must be properly documented on the DMS-615 Consent Form.
I. The original (or a copy in which all items are legible) of the completed consent form (DMS-615) must be attached to each claim submitted from each provider before payment may be approved. Providers include hospitals, ambulatory surgical centers, physicians, anesthesiologists and assistant surgeons. It is the responsibility of the physician performing the sterilization procedure to distribute correct legible copies of the signed consent form (DMS-615) to the ASC, anesthesiologist and assistant surgeon.
J. The person is informed, prior to any sterilization discussion or counseling, which no benefits or rights will be lost as a result of refusal to be sterilized and that sterilization is an entirely voluntary matter. This should be explained again just prior to the performance of the sterilization.
The responsibility for properly submitting forms rests with the provider.

Credits

Eff. Nov. 1, 2007; Oct. 13, 2003.
<Editor’s Note: Nonfunctioning links so in original.>
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.06.3-216.300, AR ADC 016.06.3-216.300
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