CommercialPrior AuthHigh impact
Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice
Providence Health Plan·Orthopedics, Podiatry, Sports Medicine·Prior Authorization
Effective date
May 11, 2026
We identified it
May 1, 2026
Summary
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.
Action Required
By May 11, 2026: (1) Billing team must update prior authorization submission process to explicitly flag when any listed CPT code will be performed at hospital outpatient setting (place of service 22). (2) Providers must obtain signed attestation from Providence Health Plan confirming ASC availability and file prospectively, or include attestation statement on PA request if no geographically accessible ASC is available. Submit attestation form (available at providencehealthplan.com) now to prevent future PA delays. (3) Update billing software and PA submission templates to capture site-of-service information for all knee arthroscopy (CPT 29873-29889), shoulder arthroscopy (CPT 23430, 29806-29828), and small joint surgery codes (CPT 28110, 28285, 28289-28299, 28306, 28308, 28315, 28750). (4) Train billing staff and providers that medical necessity for outpatient hospital setting will be evaluated separately from procedure medical necessity; if denied for outpatient setting, procedure must be rescheduled to ASC or coverage will be denied. (5) Do not submit PAs without clearly indicating site of service or attesting to ASC unavailability, as this will delay review.