CommercialPrior AuthHigh impact
Special Alert November 2025 - 2026 Outpatient Site of Service
Providence Health Plan·General Surgery, Gastroenterology·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Nov 1, 2025
Summary
Effective 1/1/2026, Providence Health Plan (Commercial Fully Insured only) now requires prior authorization for hernia repair and laparoscopic cholecystectomy procedures performed at hospital outpatient departments (place of service 22). Services must be performed at an ASC unless medical necessity criteria are met; the 3-hour surgery duration criterion has been removed as a valid reason for hospital outpatient use. Providers without accessible ASC privileges must file attestation to avoid claim denials.
Action Required
By December 15, 2025: (1) Billing team must update prior authorization system to require auth for all 14 affected CPT codes (47562, 47563, 47564, 43281, 43282, 49505, 49520, 49525, 49550, 49555, 49591, 49613, 49650, 49651) when billed with place of service 22 (hospital outpatient). (2) Configure system to route these authorizations to Providence for site-of-service medical necessity review. (3) Update encounter templates and provider order entry to flag when these procedures are scheduled at hospital outpatient vs. ASC. (4) Providers must immediately submit signed ASC accessibility attestation to Providence (link provided in policy) if no geographically accessible ASC with hospital privileges is available; prospective attestation is encouraged to prevent authorization delays. (5) Train billing and authorization staff that failure to obtain prior auth or performing at hospital outpatient without meeting medical necessity criteria will result in claim denial. (6) On all PA requests for these procedures at place of service 22, clearly document the site of service and include attestation statement if no ASC is available. NOTE: This policy applies ONLY to Providence commercial fully insured plans; does NOT apply to Medicare or OHP members.