Our new Medical Policy: Site of Service Utilization for Medicare Advantage plans will go into effect March 1, 2021. Here are more details about the policy.
This policy applies to all Medicare Advantage members, including members with dual special needs plans (D-SNP).
Please remember, if service will be provided to a Medicare Advantage member in a preferred site after March 1, preauthorization will not be required.
For example, if you provide a colonoscopy at an ambulatory surgical center, you do not need to get prior approval. You only need preauthorization if the colonoscopy is scheduled after March 1 in a hospital setting.
Services listed in the office-based code list can be performed in a doctor’s office without prior approval. Preauthorization will be 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.
Here’s a table to help you understand when you need to submit a site-of-service preauthorization request for Medicare Advantage members after March 1, 2021.
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. |
