All PlansPrior AuthHigh impact
Surgical Site of Care - Colonoscopy and Sigmoidoscopy
Regence BlueShield·Gastroenterology·Prior Authorization
Effective date
Jul 1, 2026
We identified it
Jul 7, 2026
Summary
This new policy establishes prior authorization requirements for colonoscopy and sigmoidoscopy procedures performed in hospital outpatient departments instead of ambulatory surgery centers (ASCs) or physician offices. The policy defines 27 specific medical criteria (A-CC) that must be met for hospital outpatient site of care to be considered medically necessary. Procedures not meeting these criteria will require denial or redirection to ASC/office settings.
Action Required
By June 30, 2026: (1) Billing team must implement prior authorization workflows in billing system to flag colonoscopy and sigmoidoscopy procedures planned for hospital outpatient departments. (2) Clinical/authorization staff must review submitted claims against the 27 medical necessity criteria (A-CC) documented in patient records before approving hospital outpatient site of care. (3) Update intake/encounter forms to prompt providers to document which specific criterion (A-CC) justifies hospital outpatient setting if applicable. (4) Train front-desk and prior authorization staff on ASA Physical Status Classification system and other clinical criteria. (5) Establish process to deny or redirect claims to ASC when criteria are not met. (6) Communicate to in-network gastroenterology practices that diagnostic colonoscopy/sigmoidoscopy requires documented signs/symptoms, and that geographic/facility limitations must be verified before authorizing hospital outpatient setting. Failure to implement prior auth review will result in claim denials for procedures not meeting medical necessity criteria.