Prior Authorization Required for Hospital Outpatient Setting

Preauthorization is required for procedures planned in a hospital outpatient (HOPD) site of service. Submit a preauthorization request prior to the scheduled service to avoid claim denial.

• Applies to site-of-service procedures requested to be performed in the outpatient hospital setting.
• If services are not preauthorized to be performed in the outpatient hospital setting, the claim will be denied.

Provider Action / Short Callout

Providers must request prior authorization and provide supporting clinical information when seeking HOPD placement for a procedure. Failure to request authorization or to document medical necessity may result in claim denial.

• Request prior authorization before scheduling the procedure in the hospital outpatient setting.
• Include the clinical rationale for why a less intensive setting (e.g., ASC) is not appropriate.

Clinical Documentation to Support Hospital Setting

When requesting HOPD authorization, include thorough clinical documentation to justify the hospital setting. Documentation should clearly demonstrate the member’s current clinical status and why the services cannot be safely or effectively provided in a lower‑intensity outpatient setting.

• Relevant medical records, history, and physical exam findings supporting instability or complexity.
• Operative or procedure-specific risk factors (e.g., anticipated need for transfusion; bleeding disorder requiring factor/products).
• Cardiac conditions (e.g., symptomatic arrhythmia despite medication; ongoing cardiac ischemia; recent MI within 3 months; DES within 1 year or BMS/angioplasty within 90 days unless agreed plan to continue antiplatelet therapy).
• Respiratory conditions (e.g., COPD; poorly controlled asthma with FEV1 < 80%).
• Neurologic events (e.g., CVA/TIA within past 3 months).
• Cardiac failure or valvular disease (e.g., uncompensated CHF NYHA III/IV; severe valvular heart disease).
• Metabolic/critical conditions (e.g., uncontrolled diabetes with recurrent DKA or severe hypoglycemia; end‑stage renal disease on dialysis with hyperkalemia).
• Special populations or circumstances (e.g., pregnancy; age < 18 years; developmental or cognitive status requiring higher level of care).
• Facility/equipment needs (no geographically accessible ASC with necessary specialized equipment such as fluoroscopy, laser, operating microscope, nonstandard scopes).
• Any ASC-specific restrictions that prevent safe care (weight or other health condition limitations).
• Documentation of clinical instability or susceptibility to complications with the requested procedure.

Denial for Lack of Preauthorization

Claims for procedures performed in the hospital outpatient setting without prior authorization and adequate clinical documentation will be denied.

• Denial reason: Lack of preauthorization and/or insufficient documentation to support hospital outpatient site-of-service.
• Providers may appeal with documentation demonstrating medical necessity and retroactive authorization only when plan rules allow.

Prior authorization required for listed procedures (e.g., cataract, colonoscopy, upper GI endoscopy)

Prior authorization is required for the hospital outpatient site of service for the procedures listed in the policy reference code list (examples include cataract surgery, ophthalmologic procedures, colonoscopy, and upper gastrointestinal endoscopy).

• Example procedure codes in the policy: 66821, 66982, 66984, 66987, 66988 (cataract); 45378, 45380, 45384, 45385 (colonoscopy); 43235, 43239, 43249 (upper GI endoscopy); multiple ophthalmologic codes listed in the policy reference.
• Listing of a code does not by itself imply coverage; follow prior authorization and medical necessity review.