Ambulatory Surgical Centers (ASC) & Hospitals

Prior Authorization is Required for Services Performed in an ASC/Hospital.

1. Please complete the Hospital and ASC Assessment Form; Submit a treatment plan and a detailed narrative of why the services need to be performed in an ASC/Hospital setting.
   • Hospital and ASC Assessment Form


2. Please refer to Liberty’s ASC Hospital Dental Office General Anesthesia Reimbursement Policy for more information.
   • ASC Hospital Dental Office General Anesthesia Reimbursement Policy

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