All PlansPrior AuthHigh impact
Surgical Site of Care - Hospital Outpatient
Regence BlueShield·Prior Authorization
Effective date
May 1, 2026
We identified it
Jun 16, 2026
Summary
New prior authorization policy for surgical site of care determines when hospital outpatient departments can be used instead of ambulatory surgery centers. The policy establishes 28 specific medical criteria that justify hospital outpatient surgery, including ASA Class III+ patients, BMI >40, complex medical conditions, and geographic access limitations.
Action Required
By May 1, 2026: Billing team must implement prior authorization workflow for all surgical procedures performed in hospital outpatient departments. Update billing system to flag hospital outpatient surgeries for prior auth review. Train staff to document medical necessity criteria (ASA classification, BMI, comorbidities, geographic limitations) before scheduling. Create checklist of 28 qualifying criteria for providers. Claims without proper prior authorization will be denied.