Surgical Site of Care- Hospital Outpatient

REQUIREMENTS: - By September 1, 2026: Billing team must update prior authorization system to require site-of-care documentation and validation against all 30 criteria listed in Policy UM19 before approving hospital outpatient surgical procedures. - By September 1, 2026: Providers must be notified that hospital outpatient surgical procedures now require prior authorization review demonstrating medical necessity per criteria I.A through I.DD. Update provider portal and billing guidelines documentation. - Update claim submission templates and encounter forms to capture documentation supporting medical necessity criteria (e.g., ASC availability within 25 miles, physician privileges, ASA classification, comorbidities, BMI, medication requirements). - Implement pre-authorization checklist in billing system requiring providers to document which specific criteria (I.A-I.DD) justify hospital outpatient setting rather than ASC. - Train prior authorization staff on ASA Physical Status Classification system and all 30 medical necessity criteria to properly validate requests. - Flag and deny claims for hospital outpatient surgical procedures lacking documented medical necessity per criteria I unless procedure-specific prior authorization is not required by plan. - Note: Policy does NOT apply to ASC, physician office, or emergency facility procedures. Verify procedure codes against plan's covered procedure list before applying site-of-care requirements.