All PlansPrior AuthHigh impact
Surgical Site of Care- Hospital Outpatient
Regence BlueShield·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Jun 16, 2026
Summary
New prior authorization policy effective July 1, 2026 establishes specific medical necessity criteria for surgical procedures performed in hospital outpatient departments instead of ambulatory surgery centers (ASCs). The policy requires prior authorization to justify hospital outpatient site of care and includes extensive criteria covering patient health status, facility availability, and procedure complexity.
Action Required
Before July 1, 2026: Billing team must implement prior authorization requirements for all surgical procedures performed in hospital outpatient departments when ASCs are available. Update billing system to flag cases requiring site-of-care authorization. Train staff on the 30+ medical necessity criteria including ASA classification III+, BMI >40, cardiovascular conditions, pulmonary risks, and facility limitations. Providers must document medical necessity meeting at least one specified criterion. Claims without proper authorization will be denied.