CommercialPrior AuthHigh impact
Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice
Providence Health Plan·Orthopedics, Sports Medicine, General Surgery·Prior Authorization
Effective date
May 11, 2026
We identified it
Sep 2, 2026
Summary
Effective May 11, 2026, Providence Health Plan will add a new medical necessity review specifically for the site of service (hospital outpatient vs. ASC) for knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures on commercial fully insured groups. If medical policy criteria are not met for hospital outpatient placement, the procedure must be performed at an ASC for coverage. Providers must either have a signed attestation on file or indicate on the prior authorization request if no geographically accessible ASC is available.
Action Required
By May 11, 2026: Billing team must update prior authorization workflows to include site of service medical necessity review for all 33 affected CPT codes (knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures). Update encounter forms and EMR templates to require providers to clearly indicate on PA requests if the procedure will be performed at a hospital outpatient setting (place of service 22). Immediately: Providers performing these procedures must submit a prospective attestation to Providence Health Plan if no geographically accessible ASC is available, or indicate this on each PA request to prevent authorization delays. Upload attestation forms (available at ProvidenceHealthPlan.com) to provider records. Failure to comply will result in claim denials if medical policy criteria are not met for outpatient hospital placement and the procedure is not rerouted to an ASC. Contact PHPMedicalPolicyInquiry@providence.org for questions or to request the complete medical policy.