Special Alert March 2026 - Outpatient Surgical Site of Service Notice

Previously due 2026-05-11 (date passed; verify current applicability), billing and prior authorization teams must: (1) Update prior authorization workflows to require medical necessity review for hospital outpatient site of service (place of service 22) in addition to existing procedure-level prior authorization for all 43 specified CPT codes across knee arthroscopy, shoulder arthroscopy, and small joint surgery categories; (2) Require providers to clearly indicate on PA requests if any listed procedures will be performed in hospital outpatient setting; (3) Implement requirement that if medical policy criteria are not met for outpatient hospital site, the service must be performed at an ASC for coverage or claim will be denied; (4) Providers must either file signed attestation with Plan confirming ASC access/privileges or indicate on each PA request that no geographically accessible ASC is available to prevent authorization delays; (5) Encourage providers to complete prospective attestations immediately and use Care Advance Provider Portal medical necessity questionnaires to streamline process and enable automatic authorization when criteria are met. NOTE: This applies to Commercial Fully Insured Groups only and does not apply to Providence Medicare or Providence OHP members.