Our new Medical Policy: Site of Service Utilization for commercial plans went into effect Aug. 1. Please remember, if you are providing a service in a preferred site, preauthorization is not required.
For example, if you are providing a colonoscopy at an ambulatory surgical center, you do not need to get prior approval. You only need preauthorization if the colonoscopy is scheduled in a hospital setting.
Services listed in the office-based code list can be performed in a doctor’s office without prior approval. Preauthorization is required for these procedures to be performed at an ambulatory surgical center or outpatient hospital, including hospital-owned, off-campus facilities.
Services listed in the outpatient hospital code list do not require preauthorization when they are being done in an ambulatory surgical center. Preauthorization is required when the services are being performed in an outpatient hospital, including hospital-owned, off-campus facilities.
Please note, this site-of-service utilization policy does not apply to members who are age 18 or younger.
Here’s a table to help you understand when you need to submit a site-of-service preauthorization request:
|Services||Doctor’s office||Ambulatory surgical center||Outpatient hospital, including hospital-owned, off-campus facilities|
|Services/procedures on office-based code list||No preauthorization needed.||Yes, preauthorization required.||Yes, preauthorization required.|
|Services/procedures on outpatient hospital code list||N/A||No preauthorization needed.||Yes, preauthorization required.|