All PlansPrior AuthHigh impact
Surgical Site of Care - Colonoscopy
Regence BlueShield·Gastroenterology, General Surgery, Internal Medicine +1 more·Prior Authorization
Effective date
Jan 21, 2026
We identified it
Jun 17, 2026
Summary
New prior authorization policy establishes medical necessity criteria for performing colonoscopies in hospital outpatient departments instead of ambulatory surgery centers or physician offices. The policy lists 28 specific medical conditions and circumstances that justify hospital-based colonoscopy procedures.
Action Required
By January 21, 2026: Billing team must implement prior authorization requirements for all colonoscopies performed in hospital outpatient departments. Update billing software to flag hospital-based colonoscopy claims for prior auth review. Train staff to verify patients meet one of the 28 medical necessity criteria (ASA III+, BMI >40, cardiovascular conditions, etc.) before scheduling hospital procedures. Ensure documentation includes required medical conditions to support site of care determination. Claims may be denied if medical necessity criteria are not met.