Special Alert March 2026 - Outpatient Surgical Site of Service Notice

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) in addition to existing procedure prior authorization for all 43 listed CPT codes related to knee arthroscopy, shoulder arthroscopy, and small joint surgery. (2) Update encounter forms and billing system templates to require providers to specify planned site of service (hospital outpatient vs. ASC) for these procedures. (3) Obtain and file signed attestation from all providers regarding ASC accessibility, or document attestation submission date in system to prevent prior auth delays. (4) If attestation is not on file, train billing staff to instruct providers to note "no ASC available" on PA requests for these procedures. (5) Encourage providers to use Providence Care Advance Provider Portal for medical necessity questionnaires to enable automatic authorization when criteria are met. (6) Create internal alert system to flag any PA requests for these codes performed at hospital outpatient setting (place of service 22) for additional medical necessity screening. Failure to obtain site-of-service medical necessity review will result in claim denials; services performed at hospital outpatient setting without approval will require rework or ASC repositioning.