CommercialPrior AuthHigh impact
Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice
Providence Health Plan·Orthopedics, Sports Medicine, General Surgery +1 more·Prior Authorization
Effective date
May 11, 2026
We identified it
Jul 2, 2026
Summary
Effective May 11, 2026, Providence Health Plan will add medical necessity review 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 outpatient hospital site does not meet medical policy criteria, the procedure must be performed at an ASC for coverage. Providers without geographically accessible ASC must file an attestation or note ASC unavailability on prior authorization requests.
Action Required
By May 11, 2026: (1) Billing team must update prior authorization workflows to require medical necessity review for hospital outpatient site of service (place of service 22) for all listed CPT codes. (2) For each PA request involving these procedures at hospital outpatient settings, clearly indicate place of service 22 on the prior authorization submission. (3) Immediately: Providers must either submit a prospective attestation to Providence Health Plan (available at the URL referenced) confirming ASC access/privileges, or be prepared to indicate on each PA request if no geographically accessible ASC is available. (4) Update encounter forms and billing templates to prompt providers to specify site of service for these procedures. (5) If medical necessity criteria are not met for outpatient hospital setting, claims will be denied unless the procedure is performed at an ASC instead. (6) Contact PHPMedicalPolicyInquiry@providence.org with questions. This applies to Providence commercial fully insured groups only—not Medicare Advantage or OHP members.