47564 Insurance Policy Changes

Special Alert November 2025 - 2026 Outpatient Site of Service

Effective 1/1/2026, Providence Health Plan (Commercial Fully Insured only) now requires prior authorization for hernia repair and laparoscopic cholecystectomy procedures performed at hospital outpatient departments (place of service 22). Services must be performed at an ASC unless medical necessity criteria are met; the 3-hour surgery duration criterion has been removed as a valid reason for hospital outpatient use. Providers without accessible ASC privileges must file attestation to avoid claim denials.