Sec. 10.67.06.03. Benefits — Physician and Advanced Practice Nurse Specialty Care Services

A. An MCO shall provide to its enrollees medically necessary specialty care services that are outside of the enrollee's PCP's scope of practice, or, in the judgment of the enrollee's PCP, are not services that the PCP customarily provides, is specifically trained for, or is experienced in and are provided by:

(1) A physician or an advanced practice nurse, acting within the scope of the individual's license or certification, training, and experience;

(2) A practitioner other than a physician or an advanced practice nurse when the practitioner is in a physician's employ, is under the physician's direct supervision, and performs the service within the scope of the practitioner's license, certification, or other legal authorization, for the purpose of assisting in the provision of the specialty care service;

(3) A clinic that furnishes health care services by or under the direction of a physician; or

(4) For enrollees who are younger than 21 years old, a doctor of dental medicine or dental surgery, if the services are surgical services that are also typically performed by physicians.

B. Notwithstanding §A(2) of this regulation, specialty care services provided under Regulations .04-.25 of this chapter may include medically necessary diagnostic and treatment services provided by a physician or other appropriate practitioner, acting within the scope of the practitioner's license, certification, or other legal authorization, and in accordance with the practitioner's training and experience.