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
Oct 6, 2026
Summary
Effective 1/1/2026, Providence Health Plan (Commercial Fully Insured only) will require prior authorization to review medical necessity for hospital outpatient site of service (place of service 22) for hernia repair and laparoscopic cholecystectomy procedures. Providers must perform these procedures at an ambulatory surgery center (ASC) unless medical necessity criteria are met; the 3-hour prolonged surgery criterion is being removed. Providers without geographically accessible ASC availability must submit attestation to avoid prior authorization delays.
Action Required
Previously due 1/1/2026 (date passed; verify current applicability): Billing team must implement prior authorization requirement for hospital outpatient site of service (place of service 22) for the 14 specified CPT codes related to hernia repair and laparoscopic cholecystectomy in the billing system for Providence Health Plan Commercial Fully Insured members only. Providers must clearly indicate place of service 22 on prior authorization requests for these procedures. Providers without geographically accessible ASC availability should submit a signed attestation to Providence Health Plan now (prospectively) or indicate ASC unavailability on each prior authorization request to prevent review delays. If medical policy criteria are not met for hospital outpatient site of service, claims will only be covered if performed at an ambulatory surgery center. Contact PHPMedicalPolicyInquiry@providence.org for medical policy details or questions.