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
Jul 2, 2026
Summary
Effective January 1, 2026, Providence Health Plan (Commercial Fully Insured only) now requires prior authorization to verify medical necessity before performing hernia repairs and laparoscopic cholecystectomies at hospital outpatient facilities (place of service 22). If medical criteria are not met, these procedures must be performed at an ambulatory surgery center (ASC) instead, or coverage will be denied. The policy also removes prolonged surgery (>3 hours) as a qualifying reason for hospital outpatient use.
Action Required
By December 15, 2025: Billing team must implement the following changes: (1) Update billing software to automatically flag claims for CPT codes 47562, 47563, 47564, 43281, 43282, 49505, 49520, 49525, 49550, 49555, 49591, 49613, 49650, and 49651 when submitted with place of service 22 (hospital outpatient) for Providence commercial plans, requiring prior authorization before claim submission; (2) Providers must obtain attestation from Providence Health Plan confirming ASC availability or lack thereof, and file prospectively to avoid future delays (contact PHPMedicalPolicyInquiry@providence.org or use attestation form at ProvidenceHealthPlan.com); (3) Update encounter forms and surgical scheduling workflows to prompt providers to indicate whether procedures will be performed at hospital outpatient setting and to note ASC availability; (4) Train front desk and billing staff that prolonged surgery (>3 hours) is NO LONGER an acceptable justification for hospital outpatient site of service—medical policy criteria must be met; (5) Update internal guidelines to communicate that claims for these procedures at hospital outpatient facilities without approved prior authorization or valid medical necessity will be DENIED and may require rebilling at ASC. This applies only to Providence commercial fully insured plans and does NOT apply to Medicare Advantage or OHP members.