What types of policy changes does Providence Health Plan issue?

Providence Health Plan regularly publishes coverage updates including prior authorization requirement changes, billing code additions or deletions, plan-type coverage modifications, and clinical policy revisions. PolicyChanges.app monitors these notices and summarizes the impact for providers.

How often does Providence Health Plan update its policies?

Providence Health Plan typically releases policy bulletins on a rolling basis throughout the year. Our system checks for new updates daily and adds them to this feed as soon as they are identified.

How many Providence Health Plan policy changes are tracked here?

This page currently tracks 36 documented Providence Health Plan policy changes. New items are added as they are identified.

What should I do when Providence Health Plan changes a prior authorization policy?

Review each change's effective date and action-required notes. Update your billing and clinical workflows before the effective date to avoid claim denials. Each policy detail page on PolicyChanges.app includes a plain-English summary and action items.

Providence Health Plan Policy Changes & Prior Auth Updates

We track 36 documented policy changes from Providence Health Plan across OR, WA. Each entry includes an AI-generated plain-English summary, effective date, affected billing codes, and a direct link to the original Providence Health Plan notice. Use the related links below to narrow results by specialty or state, or sign up for a free daily alert to receive new Providence Health Plan updates automatically.

High impact
Special Alert May 2026 - Optum Emergency Department Claim Analyzer
Providence Health Plan·Effective Jul 1, 2026
Effective July 1, 2026, Providence Health Plan will implement the Optum Emergency Department Claim (EDC) Analyzer to review facility ED claims billed with CPT codes 99283, 99284, or 99285. Claims will be assessed against documentation of intensity, services, and patient complexity; billed levels not supported by documentation may be adjusted or denied. Professional physician ED services are unaffected.
High impact
Providence Health Plan – Behavioral Health Network Transition
Providence Health Plan·Effective Jul 1, 2026
Effective July 1, 2026, Providence Health Plan is transitioning behavioral health services from Carelon Behavioral Health to in-house management. Providers contracted directly with Providence or participating in Cigna's PPO/First Choice networks will remain in-network. Out-of-network providers will receive transition-of-care support letters, and members will receive new ID cards with updated claims submission addresses by July 1, 2026.
High impact
Special Alert May 2026 - Optum Emergency Department Claim Analyzer
Providence Health Plan·Effective Jul 1, 2026
Effective July 1, 2026, Providence Health Plan will implement the Optum Emergency Department Claim (EDC) Analyzer to review facility ED claims for Commercial and Medicare members. The tool will automatically evaluate whether billed ED levels (CPT 99283, 99284, 99285) are supported by documented intensity, services, and complexity. Claims not supported by documentation may be adjusted to the appropriate level or denied, requiring providers to ensure accurate ED leveling and complete coding.
High impact
NEW! Provider Newsletter
Providence Health Plan·Effective Jul 1, 2026
Effective July 1, 2026, Carelon Behavioral Health will no longer provide behavioral health services to Providence Health Plan members. Services will transition directly to Providence Health Plan and network partners. Providers contracted with Providence or participating in Cigna's PPO/First Choice networks will remain in-network. Members will receive new ID cards with updated claims submission addresses.
High impact
Special Alert April 2026 - Alert for 6.1 Coding and Reimbursement Policy Changes
Providence Health Plan·Effective Jun 1, 2026
Providence Health Plan is implementing four coding and reimbursement policy changes effective June 1, 2026: (1) denying inpatient sepsis claims (MS-DRG 871-872) with length of stay under 3 days discharged to home; (2) denying ED critical care codes (99291, 99292) when patients are discharged to home; (3) requiring accurate anatomical modifiers for bilateral-eligible surgical procedures or claims will be denied; (4) eliminating additional reimbursement for anesthesia physical status modifiers P3, P4, P5 on commercial plans. All changes require immediate billing system updates and provider education.
High impact
Special Alert May 2026 - UPDATE Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes
Providence Health Plan·Effective Jun 1, 2026
Providence Health Plan implemented four coding and reimbursement policy changes effective June 1 and July 1, 2026. These policies will deny inpatient sepsis claims with LOS <3 days discharged to home, deny critical care services billed in the ED when discharged to home, require specific anatomical modifiers for surgical procedures, and eliminate additional reimbursement for anesthesia physical status modifiers P3/P4/P5 on commercial plans.
High impact
Special Alert June 2026 - UPDATE Part 2 - Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes
Providence Health Plan·Effective Jun 1, 2026
Providence Health Plan implemented four coding and reimbursement policy changes effective June 1 and July 1, 2026: (1) rescinded the inpatient sepsis DRG length-of-stay edit; (2) will deny critical care services (99291/99292) billed in the ED when patients are discharged home; (3) will deny surgical procedures (CPT 10000-69999) missing required anatomical modifiers (RT, LT, E1-E4, etc.); and (4) will no longer reimburse additional units for anesthesia physical status modifiers P3, P4, P5 on commercial plans. These changes require immediate updates to billing logic, provider documentation requirements, and claim submission processes.
High impact
Special Alert May 2026 - UPDATE Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes
Providence Health Plan·Effective Jun 1, 2026
Providence Health Plan implemented four coding and reimbursement policy changes effective June-July 2026: (1) Denying inpatient sepsis claims (MS-DRG 871-872) with length of stay under 3 days discharged to home; (2) Denying critical care services (CPT 99291-99292) billed in the ED when discharged to home; (3) Requiring anatomical modifiers (RT, LT, etc.) on surgical procedures or claims will be denied; (4) Eliminating additional reimbursement for anesthesia physical status modifiers P3, P4, P5 on commercial plans. These changes require immediate billing system updates and provider communication to avoid claim denials.
High impact
Special Alert April 2026 - Alert for 6.1 Coding and Reimbursement Policy Changes
Providence Health Plan·Effective Jun 1, 2026
Providence Health Plan is implementing four new coding and reimbursement policies effective June 1, 2026: (1) denying sepsis DRG claims (871-872) with <3-day stays discharged to home; (2) denying critical care codes (99291-99292) billed in ED when discharged to home; (3) denying surgical procedures missing required anatomical modifiers; and (4) eliminating additional reimbursement units for anesthesia physical status modifiers P3, P4, P5 on commercial plans. These changes require immediate billing system updates and provider documentation reviews to prevent claim denials.
High impact
Special Alert March 2026 - Outpatient Surgical Site of Service Notice
Providence Health Plan·Effective May 11, 2026
Effective May 11, 2026, Providence Health Plan (Commercial Fully Insured Groups only) will now require medical necessity review for hospital outpatient surgical site of service (place of service 22) for knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures. If medical policy criteria are not met for outpatient hospital setting, the procedure must be performed at an ASC instead. Providers without ASC access must submit signed attestation or note ASC unavailability on prior authorization requests.
High impact
Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice
Providence Health Plan·Effective May 11, 2026
Effective May 11, 2026, Providence Health Plan will add medical necessity review for hospital outpatient site of service (place of service 22) for knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures on commercial fully insured groups. If outpatient hospital site does not meet medical policy criteria, the procedure must be performed at an ASC for coverage. Providers without geographically accessible ASC must file an attestation or note ASC unavailability on prior authorization requests.
High impact
Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice
Providence Health Plan·Effective May 11, 2026
Effective May 11, 2026, Providence Health Plan will now review medical necessity for hospital outpatient site of service (place of service 22) for knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures on commercial fully insured groups. If medical policy criteria are not met for outpatient hospital setting, procedures must be performed at an ASC for coverage. Prior authorization requirements remain in place, with the addition of site-of-service medical necessity review.
High impact
Special Alert March 2026 - Outpatient Surgical Site of Service Notice
Providence Health Plan·Effective May 11, 2026
Effective May 11, 2026, Providence Health Plan will add medical necessity review for hospital outpatient site of service (place of service 22) for knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures on commercial fully insured groups. If medical necessity criteria are not met for outpatient hospital setting, the procedure must be performed at an ASC for coverage. Prior authorization requirements remain unchanged for the procedures themselves, but now include site-of-service review.
High impact
Special Alert January 2026 - Carelon Radiotracer Management for PET Imaging
Providence Health Plan·Effective Apr 1, 2026
Effective April 1, 2026, Carelon will require submission of both PET CPT codes and radiotracer CPT codes together during the authorization process for Brain and Oncologic PET imaging procedures. Approved authorizations will specify which radiotracer categories are allowed based on clinical indication. This change affects the intake and prior authorization workflow for PET imaging claims.
High impact
Special Alert December 2025 - Taxonomy Requirements
Providence Health Plan·Effective Mar 15, 2026
Effective March 15, 2026, Providence Health Plan (PHP) and Providence Health Assurance (PHA) will require all providers to include taxonomy codes on every Medicare and Commercial claim submission. Claims submitted without correct or missing taxonomy codes will be denied. Providers must ensure their taxonomy code is registered with CMS and included in all claim submissions to avoid payment delays and denials.
High impact
Special Alert December 2025 - Taxonomy Requirements
Providence Health Plan·Effective Mar 15, 2026
Effective March 15, 2026, Providence Health Plan (PHP) and Providence Health Assurance (PHA) will require taxonomy codes on all provider-submitted Medicare and Commercial claims. Claims submitted with missing or incorrect taxonomy codes will be denied. Providers must ensure their taxonomy codes are registered with CMS and included in all claim submissions.
High impact
Special Alert March 2026 - Implementation of Multiple Surgery Reduction (MSR) Rules for Endoscopic Procedures Billed by Ambulatory Surgery Centers (ASCs)
Providence Health Plan·Effective Mar 4, 2026
Providence Health Plan is implementing Multiple Surgery Reduction (MSR) rules for endoscopic procedures billed by ASCs effective March 4, 2026. Endoscopies from the same family will follow CMS special rules (highest paid at 100%, subsequent paid at difference from base code), while unrelated endoscopies and non-endoscopic procedures will be paid at 50% MSR. This aligns ASC payments with national CMS policy and will result in reduced reimbursement for claims with multiple procedures.
High impact
Special Alert March 2026 - Implementation of Multiple Surgery Reduction (MSR) Rules for Endoscopic Procedures Billed by Ambulatory Surgery Centers (ASCs)
Providence Health Plan·Effective Mar 4, 2026
Effective March 4, 2026, Providence Health Plan is implementing Multiple Surgery Reduction (MSR) rules for endoscopic procedures billed by ASCs, aligning with CMS policy. When multiple endoscopies are performed, only the highest-valued procedure receives 100% reimbursement; subsequent procedures are paid at a reduced rate based on the difference from the base code. Endoscopies combined with non-endoscopic procedures follow standard 50% MSR rules.
High impact
Special Alert February 2026 - E&M Correct Coding - New and Existing E&M Codes
Providence Health Plan·Effective Mar 1, 2026
Effective March 1, 2026, Providence Health Plan will conduct targeted audits of practitioners billing high-level E&M services at rates significantly above peer averages. Providers with disproportionate high-level E&M billing compared to similar specialties may receive education outreach, and any high-level E&M claims lacking supporting clinical documentation will be subject to claim recoupment.
High impact
Special Alert February 2026 - E&M Correct Coding - New and Existing E&M Codes
Providence Health Plan·Effective Mar 1, 2026
Effective March 1, 2026, Providence Health Plan will conduct targeted audits to identify practitioners billing high-level E&M services at disproportionately higher rates than specialty peers. Unsupported high-level E&M claims may be subject to recoupment. Providers should ensure robust clinical documentation supports all high-level E&M coding to avoid financial penalties.
High impact
Special Alert November 2025 - 2026 Outpatient Site of Service
Providence Health Plan·Effective Jan 1, 2026
Effective January 1, 2026, Providence Health Plan (Commercial Fully Insured only) now requires prior authorization to verify medical necessity before performing hernia repairs and laparoscopic cholecystectomies at hospital outpatient facilities (place of service 22). If medical criteria are not met, these procedures must be performed at an ambulatory surgery center (ASC) instead, or coverage will be denied. The policy also removes prolonged surgery (>3 hours) as a qualifying reason for hospital outpatient use.
High impact
Special Alert December 2025 - Medicaid Benefit: Complex Rehab Technology (CRT) Repair at Providence Health Plan
Providence Health Plan·Effective Jan 1, 2026
Effective January 1, 2026, Providence Health Plan (Oregon Medicaid) eliminates prior authorization requirements for Complex Rehab Technology (CRT) repairs under Senate Bill 549. Billing teams must use modifier RB on all CRT repair claims to ensure proper processing and avoid denials. Prior authorization remains required only for CRT replacements, new equipment, upgrades, or non-repair services.
High impact
Special Alert December 2025 - Medicaid Benefit: Complex Rehab Technology (CRT) Repair at Providence Health Plan
Providence Health Plan·Effective Jan 1, 2026
Effective January 1, 2026, Providence Health Plan (Oregon Medicaid) eliminates prior authorization requirements for Complex Rehab Technology (CRT) repairs under Senate Bill 549. Providers must bill all CRT repair claims using modifier RB to ensure proper processing and avoid denials. Prior authorization is still required only for CRT replacements, new equipment/upgrades, or items that don't meet the SB 549 CRT definition.
High impact
Special Alert November 2025 - 2026 Outpatient Site of Service
Providence Health Plan·Effective Jan 1, 2026
Effective 1/1/2026, Providence Health Plan (Commercial Fully Insured only) now requires prior authorization for hernia repair and laparoscopic cholecystectomy procedures performed at hospital outpatient departments (place of service 22). Services must be performed at an ASC unless medical necessity criteria are met; the 3-hour surgery duration criterion has been removed as a valid reason for hospital outpatient use. Providers without accessible ASC privileges must file attestation to avoid claim denials.
High impact
Special Alert October 2025 - Neuraxial Labor Analgesia/Anesthesia
Providence Health Plan·Effective Dec 1, 2025
Effective 12/1/2025, Providence Health Plan will cap reimbursement for neuraxial labor analgesia/anesthesia (CPT 01967) at 480 units (480 minutes) for all non-Medicaid lines of business. Any units billed in excess of this 480-unit cap will be denied. Billing teams must implement system edits to prevent claim denials.
High impact
Special Alert October 2025 - Neuraxial Labor Analgesia/Anesthesia
Providence Health Plan·Effective Dec 1, 2025
Effective December 1, 2025, Providence Health Plan will cap reimbursement for CPT 01967 (neuraxial labor analgesia/anesthesia for planned vaginal delivery) at 480 units (480 minutes) for all non-Medicaid lines of business. Any units billed in excess of this cap will be denied. This is a new policy that introduces a hard limit on anesthesia time reimbursement for this procedure.
High impact
Special Alert June 2025 - American Specialty Health (ASH) Notification
Providence Health Plan·Effective Sep 1, 2025
American Specialty Health (ASH) will now handle utilization management, prior authorization, and claims payment for chiropractic, acupuncture, naturopathic, and therapeutic massage services. Claims must be submitted to ASH instead of Providence Health Plan, and providers are responsible for obtaining medical necessity approval before delivering services to in-network members.
High impact
Special Alert August 2025 - Benign Skin Lesion Removal Billing Guidelines
Providence Health Plan·Effective Aug 1, 2025
Providence Health Plan issued a critical billing update for benign skin lesion removal procedures effective immediately (August 2025). Claims must now be billed with specific diagnosis code groupings—Group 1 requires a single listed diagnosis, Group 2 requires diagnoses from both Column A and Column B, and Group 3 (malignant diagnoses) applies only to CPT 11300-11313. Claims submitted without proper diagnosis code pairing will be denied as not medically necessary.
High impact
Special Alert August 2025 - Benign Skin Lesion Removal Billing Guidelines
Providence Health Plan·Effective Aug 1, 2025
Providence Health Plan updated benign skin lesion removal billing guidelines effective immediately (August 2025). Claims for CPT codes 11300-11313, 11400-11446, and 17110-17111 must now be billed with specific diagnosis code groupings (Group 1, Group 2, or Group 3) to be considered medically necessary. Claims submitted without compliant diagnosis codes will be denied as not medically necessary.
Medium impact
Special Alert January 2026 - Carelon Radiotracer Management for PET Imaging
Providence Health Plan·Effective Apr 1, 2026
Effective April 1, 2026, Carelon will require both PET and radiotracer CPT codes to be submitted together during the authorization process for Brain PET and Oncologic PET procedures. Approved authorizations will specify which radiotracer categories are allowed based on clinical guidelines. This change affects the prior authorization workflow and claims submission process for PET imaging services.
Medium impact
Special Alert October 2025 - Electrolysis Documentation Requirements
Providence Health Plan·Effective Dec 1, 2025
Effective 12/1/2025, Providence Health Plan now requires specific clinical documentation for all electrolysis claims related to gender affirmation services on Commercial and Medicare lines of business. Documentation must include diagnosis of gender incongruence/dysphoria, WPATH SOC-8 alignment statement, clinical rationale, detailed treatment plan with session counts, and treatment area descriptions. This requirement does NOT apply to Providence OHP members.
Medium impact
Special Alert October 2025 - Electrolysis Documentation Requirements
Providence Health Plan·Effective Dec 1, 2025
Effective December 1, 2025, Providence Health Plan requires specific documentation for all electrolysis claims related to gender affirmation on Commercial and Medicare lines of business. Documentation must include: gender dysphoria/incongruence diagnosis, WPATH SOC-8 alignment statement, clinical rationale, treatment plan with specific areas and session counts, and treatment area descriptions. This requirement applies to provider-submitted claims and direct member reimbursement requests, but excludes Providence OHP members.
Medium impact
Special Alert July 2026 - Update to Health Share’s Clinical Practice Guidelines
Providence Health Plan·Identified Aug 1, 2026
Health Share of Oregon has updated its Clinical Practice Guidelines, replacing CDC ACIP immunization guidelines with the AAP Immunization Schedule. Billing teams must review the updated guidelines at the provided link to identify any changes to covered immunization services, coding requirements, or clinical documentation standards that may affect claim submissions.
Medium impact
Special Alert July 2026 - Update to Health Share’s Clinical Practice Guidelines
Providence Health Plan·Identified Jul 15, 2026
Health Share of Oregon has updated its Clinical Practice Guidelines, replacing CDC ACIP immunization guidelines with the AAP Immunization Schedule. Billing teams must review the updated guidelines at the provided link to identify which immunization codes and protocols have changed to ensure accurate claim submission and compliance with the new standards.
Medium impact
Special Alert June 2026 - UPDATE Part 2 - Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes
Providence Health Plan·Identified Jul 2, 2026
Failed to analyze policy change
Medium impact
Coding Policy Alert May/June 2025
Providence Health Plan·Identified Jun 1, 2025
Failed to analyze policy change

Providence Health Plan in OR Providence Health Plan in WA Providence Health Plan: Allergy & Immunology Providence Health Plan: Anesthesiology Providence Health Plan: Chiropractic Providence Health Plan: Critical Care All payers

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Providence Health Plan Policy Changes 2026 | Prior Auth & Coverage Updates | PolicyChanges.app

Special Alert May 2026 - Optum Emergency Department Claim Analyzer

Providence Health Plan – Behavioral Health Network Transition

Special Alert May 2026 - Optum Emergency Department Claim Analyzer

NEW! Provider Newsletter

Special Alert April 2026 - Alert for 6.1 Coding and Reimbursement Policy Changes

Special Alert May 2026 - UPDATE Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes

Special Alert June 2026 - UPDATE Part 2 - Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes

Special Alert May 2026 - UPDATE Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes

Special Alert April 2026 - Alert for 6.1 Coding and Reimbursement Policy Changes

Special Alert March 2026 - Outpatient Surgical Site of Service Notice

Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice

Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice

Special Alert March 2026 - Outpatient Surgical Site of Service Notice

Special Alert January 2026 - Carelon Radiotracer Management for PET Imaging

Special Alert December 2025 - Taxonomy Requirements

Special Alert December 2025 - Taxonomy Requirements

Special Alert March 2026 - Implementation of Multiple Surgery Reduction (MSR) Rules for Endoscopic Procedures Billed by Ambulatory Surgery Centers (ASCs)

Special Alert March 2026 - Implementation of Multiple Surgery Reduction (MSR) Rules for Endoscopic Procedures Billed by Ambulatory Surgery Centers (ASCs)

Special Alert February 2026 - E&M Correct Coding - New and Existing E&M Codes

Special Alert February 2026 - E&M Correct Coding - New and Existing E&M Codes

Special Alert November 2025 - 2026 Outpatient Site of Service

Special Alert December 2025 - Medicaid Benefit: Complex Rehab Technology (CRT) Repair at Providence Health Plan

Special Alert December 2025 - Medicaid Benefit: Complex Rehab Technology (CRT) Repair at Providence Health Plan

Special Alert November 2025 - 2026 Outpatient Site of Service

Special Alert October 2025 - Neuraxial Labor Analgesia/Anesthesia

Special Alert October 2025 - Neuraxial Labor Analgesia/Anesthesia

Special Alert June 2025 - American Specialty Health (ASH) Notification

Special Alert August 2025 - Benign Skin Lesion Removal Billing Guidelines

Special Alert August 2025 - Benign Skin Lesion Removal Billing Guidelines

Special Alert January 2026 - Carelon Radiotracer Management for PET Imaging

Special Alert October 2025 - Electrolysis Documentation Requirements

Special Alert October 2025 - Electrolysis Documentation Requirements

Special Alert July 2026 - Update to Health Share’s Clinical Practice Guidelines

Special Alert July 2026 - Update to Health Share’s Clinical Practice Guidelines

Special Alert June 2026 - UPDATE Part 2 - Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes

Coding Policy Alert May/June 2025