All PlansPrior AuthHigh impact
Surgical Site of Care - Colonoscopy and Sigmoidoscopy
Regence BlueShield·Gastroenterology, General Surgery, Internal Medicine +1 more·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Jun 16, 2026
Summary
New prior authorization policy for hospital outpatient colonoscopy and sigmoidoscopy procedures establishes 28 detailed medical criteria that must be met to justify hospital setting over ASC or physician office. Policy includes specific requirements for cardiovascular, pulmonary, and other high-risk conditions.
Action Required
Before July 1, 2026: Billing team must implement prior authorization requirements for all colonoscopy and sigmoidoscopy procedures performed in hospital outpatient settings. Update billing system to flag these cases for prior auth review. Train staff on 28 medical necessity criteria including ASA III+ classification, BMI >40, cardiovascular risks, and other specified conditions. Develop documentation checklists for providers to ensure medical necessity criteria are properly documented. Claims without proper prior authorization will be denied.