Special Alert May 2026 UPDATE - Outpatient Surgical Site of Service Notice

Already effective as of 2026-05-11 (policy was published 2026-05-01 and newly discovered 2026-10-06): Verify whether the practice has implemented the following changes and confirm current applicability with Providence Health Plan. REQUIREMENTS: (1) Billing and prior authorization teams must flag all claims for the listed CPT codes when place of service 22 (hospital outpatient) is planned, triggering an additional medical necessity review for site of service beyond the procedure-level prior authorization already required. (2) Providers must submit a signed attestation to Providence Health Plan (available at their provider portal) confirming either geographically accessible ASC availability with privileges, or confirming no ASC is available. (3) On prior authorization requests for affected procedures planned at hospital outpatient sites, clearly indicate place of service 22 and, if applicable, note that no geographically accessible ASC is available to prevent prior authorization delays. (4) Providers are encouraged to file prospective attestations now to streamline future authorization reviews. (5) If medical necessity criteria are not met for the outpatient hospital site of service, the procedure must be rerouted to an ASC for coverage. CONSEQUENCE: Claims may be denied if site of service medical necessity is not demonstrated and procedures are not redirected to ASC. NOTE: This policy applies only to Commercial Fully Insured Groups; it does NOT apply to Providence Medicare Advantage or Providence OHP members.