Site of service for covered medical services
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Defines preferred and non-preferred settings for delivering Curative-covered medical and certain pharmacy services and the medical necessity criteria and authorization process that determine when higher-cost settings are appropriate. Applies to all Curative members and providers requesting prior authorization for services.
No material clinical or coverage changes in this revision.
Coverage Criteria — Site of Care Exceptions & Rules
Medical necessity exceptions for higher-cost site
A service may be medically necessary in a higher-cost setting if ANY of the following are met:
This policy does not apply to services that are exempt from prior authorization. Services that do not require prior authorization are excluded from site-of-care review under this policy. Additionally, any services provided during an inpatient facility admission—specifically a hospital, skilled nursing facility (SNF), or inpatient psychiatric setting—are excluded from the site-of-care requirements and prior authorization review described in this document.
Required documentation for this policy: N/A. No additional documentation requirements are specified in this section of the policy.
Clinical Thresholds & Key Clinical Values
Preferred and Non-Preferred Sites of Care (Definitions)
Provider Responsibilities, Authorization & Enforcement
Prior authorization required for site-of-care review
All medical services that require prior authorization are subject to site-of-care review under this policy. Providers must submit a prior authorization request with supporting documentation of the most appropriate site of care; authorizations may be redirected to a lower-cost site based on clinical review.
- All medical services requiring prior authorization are subject to site of care review.
- Requesting provider must submit supporting documentation with the prior authorization request.
Partial adverse determinations and next steps
If the requested site does not meet medical necessity but the service itself is medically necessary, Curative will issue a partial adverse determination and provide rationale and recommended alternate sites; the provider may request an update to the site of care.
- Curative will issue a partial adverse determination when service is necessary but requested site is not.
- Notification will include rationale for denial of site, rationale for approval of service, and recommended alternative sites.
Required documentation for site-of-care review
When submitting a site-of-care prior authorization, the requesting provider must include clinical notes and history, prior treatment records, relevant diagnostic testing, and a justification addressing the medical necessity criteria for the requested site.
- Clinical notes and history
- Prior treatment records
- Diagnostic testing (if relevant)
- Justification addressing the medical necessity criteria
Documentation status
N/A
Site-of-care denial risk — redirection to lower-cost setting
Authorizations may be redirected to a lower-cost site of care following clinical review; Curative will contact the member and requesting provider telephonically at the time of determination to explain the decision and assist in selecting an alternate setting.
- Authorization may be redirected to a lower-cost site based on clinical review.
- Curative will outreach telephonically to member and provider at time of determination.
Enforcement sanctions for policy violations
Violations of this policy may result in sanctions per the Curative Sanctions Policy, including verbal or written warning, suspension, or termination, and may also expose individuals or entities to additional civil, criminal, or equitable remedies.
- Sanctions may include verbal/written warning, suspension, or termination.
- Additional civil, criminal, and equitable remedies may apply.
Background & Purpose
This policy guides placement of procedures, infusions, imaging, and other Curative-covered services into the most clinically appropriate and cost‑effective setting by defining preferred and non‑preferred sites of care and the clinical criteria that justify use of higher‑cost settings. The policy prioritizes lower‑cost, clinically appropriate locations (for example: home infusion, office-based care, standalone diagnostic facilities, ambulatory surgical centers and ambulatory infusion sites) when safe and feasible, while identifying specific clinical, physiologic, procedural, and logistical circumstances under which a higher‑cost site (for example, hospital outpatient departments) is medically necessary.
The purpose is to ensure consistent, clinically driven site‑of‑care decisions: when equivalent care can be delivered safely in a preferred site, that site is favored; when any of the documented medical necessity exceptions are met—such as high‑acuity monitoring needs, significant surgical or anesthesia risk, physiologic instability, certain age or pregnancy considerations, respiratory/hematologic/neurologic risks, prior adverse events or lack of alternatives, or facility/resource limitations—the policy permits placement in a higher‑cost setting.
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