We are updating preauthorization policies to include site-of-service reviews for our Medicare Advantage line of business for dates of services on or after March 1, 2021. We have been conducting site-of-service reviews for our commercial plans since August 2019.
We will review preauthorization requests for certain non-emergency surgical services and/or procedures to determine if the proposed site of service is medically appropriate for the service or procedure. This will apply to all Medicare Advantage members after March 1, 2021.
This update is aimed at making sure members receive care in the most appropriate setting. Under the new policy, providers will need to submit preauthorization requests if:
- Office-based procedures are provided in an outpatient hospital or ambulatory surgery, or
- Certain outpatient surgical procedures are provided in an outpatient hospital, including hospital-owned, off-campus facilities.
Affected services include, but are not limited to: dermatology, gastrointestinal, gynecological, orthopedic, ophthalmologic and urologic procedures. Refer to the policy to see the affected medical codes.
Providers who have ordered or scheduled affected services for dates on or after March 1, 2021 should make sure to obtain authorizations before services are performed on ConnectiCare Medicare Advantage members. If providers do not get the site-of-service approvals for affected medical services, claims may be denied, and members cannot be billed for the services.