ModifiedFlorida BluePolicy N/A

Site of Care Review Process

Defines Florida Blue, Florida Blue HMO, and Truli plans' Site of Care Review Process requiring prior authorization and comparative-effectiveness review for a list of Designated Outpatient Procedures when performed in a hospital outpatient department, effective October 1, 2025; excludes certain products and ASCs.

Policy Summary

PayerFlorida Blue

PolicySite of Care Review Process

Policy CodePolicy N/A

Change TypeAdded/Clarified site-of-care prior authorization

Effective DateOct 1, 2025

Next Review Date

Key ActionFor Designated Outpatient Procedures performed in a hospital outpatient department, providers must submit authorization requests via Availity Essentials and attach required clinical documentation; faxed authorizations will be returned.

POLICY UPDATE CHANGES

Site of Care Review Process requiring prior authorization for designated hospital outpatient procedures effective October 1, 2025.

Appendix of Designated Outpatient Procedure CPT codes included.

ASC is an alternative site of care and not included in the Site of Care Review.

150+Designated Outpatient Procedures (CPT codes listed)

2025-10-01Effective Date for Site of Care Review

Exclusions notedProducts excluded (e.g., Medicare Advantage, FEP, BlueCard ASO, grandfathered plans)

What Is Changing — Summary

Florida Blue is instituting a comparative-effectiveness Site of Care Review that extends existing prior authorization programs to encourage lower-cost sites of service (for example, Ambulatory Surgery Centers) when clinically appropriate. The program targets a specified list of hospital outpatient procedures (the "Designated Outpatient Procedures") and requires prior authorization when the site of service is a hospital outpatient department, effective October 1, 2025.

Ambulatory Surgery Centers (ASCs) are excluded from this Site of Care Review (ASCs may still have plan-specific prior authorization rules). The Site of Care Medical Coverage Guideline (MCG) that describes medical necessity criteria and exceptions will be available on FloridaBlue.com starting September 15, 2025 and an authorization must be submitted via Availity when the requested site is a hospital outpatient department.

Certain products are excluded from the review, including Medicare Advantage, Federal Employee Program State Account, BlueCard Administrative Services Only, and grandfathered plans.

Key facts

Effective date2025-10-01

Site of Care MCG available2025-09-15 on FloridaBlue.com

Scope - plans includedFlorida Blue, Florida Blue HMO, and Truli

Exclusions - products not subject to reviewMedicare Advantage; Federal Employee Program (FEP) State Account; BlueCard Administrative Services Only (ASO); grandfathered plans

Prior authorization submission requirementAuthorization required via Availity Essentials when site of care is an outpatient hospital

ASC statusAmbulatory Surgery Centers (ASCs) are excluded from this Site of Care Review (ASC prior auth may still apply per plan)

Designated Outpatient Procedure Codes (Appendix)

Designated Outpatient Procedure CPT codes (require prior authorization when hospital outpatient site requested)CPTCovered

11770	Excision of pilonidal cyst or sinus; simple.
11772	Excision of pilonidal cyst or sinus; complicated.
14040	Adjacent tissue transfer or rearrangement; forehead, cheeks, chin, mouth, neck.
14060	Adjacent tissue transfer or rearrangement; eyelids, nose, ears and/or lips; defect 10 sq cm or less.
14301	Adjacent tissue transfer or rearrangement; any area; defect 30.1 sq cm to 60.0 sq cm.
19120	Excision of breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions.
19125	Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion.
20610	Arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound guidance.
20680	Removal of implant; deep (e.g., buried wire, screw; metal band, nail, rod or plate) pin.
21320	Closed treatment of nasal bone fracture with manipulation; with stabilization.

1–10 of 138

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Coverage, Denial, and Exceptions — Hospital Outpatient Requests

Action Required — Prior Authorization & Documentation

Prior Authorization

Prior authorization required for hospital outpatient site

For Designated Outpatient Procedures performed in a hospital outpatient department, submit prior authorization requests via Availity Essentials. Hospital outpatient requests for codes in the Appendix require prior authorization when the site is hospital outpatient; faxed in-network requests will be returned and must be resubmitted through Availity.

Effective October 1, 2025
Faxes from in-network providers will be returned and must be resubmitted through Availity; the Florida Blue Utilization Management call center will not enter authorizations manually.

Documentation Required

Attach clinical documentation to authorization

In-network providers must attach clinical documentation to the Availity authorization request and use the Availity Authorization/Referral Inquiry tool for authorization status requests.

Definitions & Where to Find the Site of Care Medical Coverage Guideline

Designated Outpatient Procedures: A specific list of CPT codes provided in the Appendix to the bulletin that will be subject to Site of Care Review when performed in a hospital outpatient department. The Appendix lists the individual CPT codes (Designated Outpatient Procedure CPT codes) that require prior authorization when the site is a hospital outpatient location.

Site of Care MCG: The Site of Care Medical Coverage Guideline (MCG) defines the medical necessity criteria and exceptions used in the comparative-effectiveness review of hospital outpatient requests. The Site of Care MCG will be available on FloridaBlue.com starting September 15, 2025 (Providers: FloridaBlue.com → For Providers → Medical and Pharmacy Policies → Medical Policies; search "Site of Care Outpatient Procedures").

Program purpose: The Site of Care Review is an extension of Florida Blue, Florida Blue HMO, and Truli's prior authorization program to perform a comparative-effectiveness review of certain hospital outpatient procedures. The intent is to determine whether the requested hospital outpatient service can be provided in an alternative, lower-cost location of service (for example, an ASC) with equivalent therapeutic or diagnostic results and thereby encourage use of lower-cost sites when clinically appropriate.

The review specifically targets the specified Designated Outpatient Procedures (listed in the Appendix) when requested to be performed in a hospital outpatient department and may result in denial if the hospital site does not meet the comparative-effectiveness criteria or qualify for an exception.

FAQs

Question	Answer
When is the Site of Care Review effective?	Effective October 1, 2025; Site of Care MCG available on FloridaBlue.com starting September 15, 2025.
What if the requested site is an outpatient hospital?	An authorization must be submitted via Availity; Florida Blue will review whether the hospital site meets comparative-effectiveness criteria and may deny if not.
Are ASCs included?	No. Services performed at ASCs are not included in this Site of Care Review Process, though ASC prior authorization may apply depending on plan design.
Which products are excluded from this review?	Medicare Advantage, Federal Employee Program State Account, BlueCard Administrative Services Only, and grandfathered plans are excluded.

Policy Update Changes

2025-10-01added (is_material=true)Latest

Site of Care Review Process requiring prior authorization for designated hospital outpatient procedures effective October 1, 2025; Florida Blue will review requests for designated outpatient procedures performed in hospital outpatient locations to determine if the service can be provided in a lower-cost alternative location with equivalent therapeutic or diagnostic results and deny authorizations that do not meet the comparative-effectiveness criteria.

added (is_material=true)

Appendix of Designated Outpatient Procedure CPT codes included (large list of specific CPT codes provided) that require prior authorization when the site of care is a hospital outpatient department.