Site of Care Review Process
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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.
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.
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.
Designated Outpatient Procedure Codes (Appendix)
| 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. |
Coverage, Denial, and Exceptions — Hospital Outpatient Requests
Action Required — Prior Authorization & Documentation
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.
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.
Denial risk if lower-cost alternative available
Authorizations for hospital outpatient site will be denied if Florida Blue determines an alternative lower-cost location of service (for example, an ASC) can provide equivalent therapeutic or diagnostic results, or if the procedure does not meet the Site of Care MCG medical necessity criteria.
- Florida Blue may perform a medical necessity review of the underlying procedure prior to the Site of Care Review.
ASC procedures excluded from Site of Care Review
Services performed at Ambulatory Surgery Centers (ASCs) are not included in the Site of Care Review Process, though ASC prior authorization rules may still apply depending on the member's plan.
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
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.
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.
Ambulatory Surgery Centers (ASCs) are alternative sites of care and are not included in the Site of Care Review Process; ASC procedures may still be subject to plan-specific prior authorization requirements and are generally preferred due to lower cost and member out-of-pocket savings.
Authorization requests for Designated Outpatient Procedures performed in a hospital outpatient department must be submitted via Availity Essentials; faxes from in-network providers will be returned and the Florida Blue Utilization Management call center will not enter authorizations manually.
Site of Care Medical Coverage Guideline (MCG) will be available on FloridaBlue.com starting September 15, 2025, describing medical necessity criteria and exceptions.
Certain products are excluded from the Site of Care Review, including Medicare Advantage, Federal Employee Program State Account, BlueCard Administrative Services Only, and grandfathered plans.
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