23412 Insurance Policy Changes

Special Alert March 2026 - Outpatient Surgical Site of Service Notice

Effective May 11, 2026, Providence Health Plan will add medical necessity review for hospital outpatient site of service (place of service 22) for knee arthroscopy, shoulder arthroscopy, and small joint surgery procedures on commercial fully insured groups. If medical necessity criteria are not met for outpatient hospital setting, the procedure must be performed at an ASC for coverage. Prior authorization requirements remain unchanged for the procedures themselves, but now include site-of-service review.