CommercialPrior AuthHigh impact
[New York] Expanding Site of Care Program for musculoskeletal and surgical procedures
Anthem BCBS·NY · Orthopedics, Sports Medicine, General Surgery +1 more·Provider Bulletin
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem is expanding its Site of Care Program to require musculoskeletal and surgical procedures be performed in appropriate settings (ASCs or outpatient facilities rather than hospital outpatient departments). Precertification is now required for procedures scheduled at outpatient hospital settings to ensure clinical appropriateness. Billing teams must implement prior authorization workflows for affected MSK and surgical procedures.
Action Required
Before April 1, 2026: (1) Billing team must update billing system to flag all musculoskeletal and surgical procedures for precertification requirement when scheduled at hospital outpatient settings. (2) Update encounter forms and provider scheduling workflow to require prior authorization documentation before claims submission for outpatient hospital facility procedures. (3) Train front desk/scheduling staff and billing team on new precertification process via Availity portal (https://Availity.com). (4) Establish internal process to route MSK/surgical cases to appropriate settings (ASCs vs. hospital outpatient) and obtain precertification accordingly. (5) Communicate policy change to all providers performing musculoskeletal and surgical procedures in New York. Failure to obtain precertification for outpatient hospital procedures will result in claim denials.