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Outpatient Surgical Procedures – Site of Service (for Pennsylvania Only)
Act
by Sep 1, 2026
Effective date
Sep 1, 2026
Identified
Sep 2, 2026
Summary
UnitedHealthcare Community Plan of Pennsylvania updated its Outpatient Surgical Procedures policy to strengthen medical necessity documentation requirements. The policy now explicitly requires that patient medical records contain legible documentation of relevant medical history, physical examination, and diagnostic test results to support coverage decisions, and clarifies that such documentation does not guarantee coverage. Additional clarifications were added regarding how federal, state, and contractual requirements determine benefit coverage.
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What to do
by Sep 1, 2026 · 6 steps
01Billing and clinical teams must ensure all outpatient surgical procedure requests for Pennsylvania Medicaid members include complete medical records documentation in patient files.
02Providers must document relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures for every surgical procedure request.
03Billing team must verify documentation is legible and available before submitting claims.
04Update provider templates and encounter forms to include reminders about medical necessity documentation requirements.
05Train front-line staff to flag incomplete documentation before claim submission.
06Claims submitted without adequate supporting documentation will be subject to denial or review delays, and members should be informed that documentation does not guarantee coverage approval.
Original notice
Outpatient Surgical Procedures – Site of Service (for Pennsylvania Only)
uhcprovider.com · Always check the source before changing claims.