CurrentUnitedHealthcarePolicy CS143ID.B

Outpatient Surgical Procedures – Site of Service (for Idaho Only) – Community Plan Medical Policy

Defines medical necessity criteria for performing planned surgical procedures in a hospital outpatient department versus ambulatory surgical center (ASC) for UnitedHealthcare members in Idaho (including Idaho Medicaid Plus). Specifies clinical conditions and access limitations that make hospital outpatient department site of service medically necessary and documents medical records requirements for reviews.

Policy Summary

PayerUnitedHealthcare

PolicyOutpatient Surgical Procedures – Site of Service (for Idaho Only) – Community Plan Medical Policy

Policy CodePolicy CS143ID.B

Change TypeAdded medical records documentation language; updated references

Effective DateMay 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record fully supports medical necessity with legible history, physical exam, and pertinent diagnostic test results and make records available upon request; refer to the UnitedHealthcare Community Plan Prior Authorization List for procedures requiring prior authorization.

SourceLink

POLICY UPDATE CHANGES

Added language under Medical Records Documentation Used for Reviews specifying that benefit coverage is determined by federal/state/contractual requirements and that medical records documentation may be required but does not guarantee coverage.

Updated References section to reflect most current information and archived previous policy version CS143ID.A.

Idaho-onlyGeographic scope

MultipleCovered indications

Prior authorization required