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
Sep 2, 2026
Summary
Effective January 1, 2026, Providence Health Plan (Commercial Fully Insured only) will require prior authorization for hernia repair and laparoscopic cholecystectomy procedures performed at hospital outpatient settings (place of service 22). Services must be performed at an ambulatory surgery center (ASC) unless medical necessity criteria are met. The policy removes prolonged surgery (>3 hours) as a valid reason for hospital outpatient department use.
Action Required
By December 31, 2025: (1) Billing and authorization teams must update prior authorization workflows to require site-of-service review for all 14 listed CPT codes when place of service 22 (hospital outpatient) is indicated. (2) Providers performing these procedures must either: obtain a signed attestation on file with Providence Health Plan confirming no geographically accessible ASC is available, or indicate on each PA request that no ASC is available to prevent authorization delays. (3) Providers should submit prospective attestations NOW if anticipating future requests. (4) Update encounter forms and billing system templates to flag these CPT codes and prompt providers to specify facility type and confirm ASC availability. (5) Train front-desk and authorization staff that claims for these procedures at hospital outpatient settings will be denied if prior authorization is not obtained or if medical necessity criteria are not met. Note: This policy does NOT apply to Providence Medicare or Providence OHP members.