All PlansPrior AuthHigh impact
Surgical Site of Care - Hospital Outpatient
Regence BlueShield·General Surgery, Cardiothoracic Surgery, Orthopedics +8 more·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Jul 7, 2026
Summary
This new policy establishes prior authorization requirements for surgical procedures performed in hospital outpatient departments instead of ambulatory surgery centers (ASCs) or physician offices, effective October 1, 2026. The policy defines 30 specific medical necessity criteria that must be met for hospital outpatient site of care to be covered, including patient age, comorbidities, medication interactions, and procedure complexity. Billing teams must implement prior authorization workflows and ensure proper documentation to support medical necessity claims.
Action Required
Before October 1, 2026: (1) Billing team must configure billing system to require prior authorization for all surgical procedures billed to hospital outpatient department setting. (2) Providers must review the 30 medical necessity criteria (I.A through I.DD) and document which criteria are met before submitting claims. (3) Update encounter forms and EMR templates to include required clinical documentation fields matching criteria in Policy Section I (e.g., ASC availability within 25 miles, patient age, BMI, ASA classification, cardiac/pulmonary/renal status, medication interactions, procedure duration). (4) Create internal checklist for pre-authorization review matching the five categories: geographic/facility access, medication discontinuation risks, substance/medication interactions, hemodynamic instability history, and specific comorbidities. (5) Front desk staff must flag all outpatient surgical cases for prior auth review before scheduling. (6) Establish communication protocol with providers to request missing documentation before claim submission. Claims submitted without prior authorization or insufficient medical necessity documentation will be denied and shifted to member responsibility. Note: Policy does not address ASC, physician office, or emergency facility procedures—only hospital outpatient department site of care.