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January 30, 2024

We’re committed to providing our members access to high-quality care at the lowest price. In support of this commitment, we regularly evaluate and update our utilization management policies to ensure members are receiving the care they need in the setting that’s clinically appropriate and most cost-effective.

Effective March 1, 2024, we’re implementing site-of-service pre-authorization (PA) reviews for select hospital outpatient procedures among the following types of care:

• Cardiovascular
• Digestive
• Eye, ocular adnexa and ear
• Genitals (male and female)
• Hemic and lymphatic
• Integumentary
• Musculoskeletal
• Nervous system
• Respiratory
• Urinary

Under site-of-service PA review, when a procedure can be performed safely and effectively outside a hospital outpatient setting, the member and provider will receive a coverage denial letter advising that hospital outpatient treatment isn’t clinically appropriate. Site-of-service reviews are done solely to evaluate the clinical appropriateness of performing a procedure at a requested treatment facility; they’re separate from any medical PA requirements to determine medical necessity.

As with other PA programs, the obligation to secure PA for services rendered in hospital outpatient settings rests with providers. There’s no action for the member to take, although members receive PA approval or denial notifications. Providers are advised to check with our PA lists and can request PA using the Availity Essentials E-Auth application or via fax.

The following factors, among others, are considered when determining the appropriate site of service:

• Member’s health status
• Facility and geographic availability
• Specialty requirements
• Provider privileges

Site-of-service PA reviews will be implemented for all commercial group and Individual plans. See the complete list of procedure codes affected. We notified providers about site-of-service PA reviews in our Dec. 1, 2023, provider newsletter, The Connection℠.

Site-of-service PA reviews have become more commonplace as payers and public agencies seek to rein in provider cost increases. In May 2023, we announced site-of-service reviews effective July 1, 2023, for select hospital outpatient procedures in most of the treatment specialties listed above. In 2022, we began implementing site-of-service reviews for select colonoscopy and endoscopy services, and in April 2023, we announced site-of-service reviews for certain joint care procedures effective June 1, 2023.

Questions? Contact your account representative.