Health Care Transformation Challenge Launches to Colleges Across New Jersey

Q1. What is the Surgical and Implantable Device Management Program?
A1. Horizon BCBSNJ’s Surgical and Implantable Device Management Program, managed in coordination with TurningPoint, integrates evidence-based utilization management guidelines with clinical best practices, specialized peer-to-peer engagement, claims review and management, and advanced reporting and analytics to promote the overall health management of impacted members.

Q2. What is the relationship between Horizon BCBSNJ and TurningPoint?
A2. Horizon BCBSNJ has contracted TurningPoint for PA/MND reviews of select orthopedic surgeries requested by participating and nonparticipating physicians. It aims to help reduce surgical treatment variability, promote safety, improve the quality of care and outcomes and encourage patient support.

Q3. What services does TurningPoint perform as part of the Surgical and Implantable Device Management Program?
A3. TurningPoint provides utilization management (UM) reviews, First Level UM appeals processing, claim reviews and UM-related customer service support for certain specialized orthopedic surgeries (see question 4).

Q4. For what procedures/services does TurningPoint perform PA/MNDs as part of this program?
A4. TurningPoint performs PA/MND reviews for medical necessity and appropriate length of stay (when applicable) for:

Q5. How does TurningPoint manage the specialized orthopedic surgeries?
A5. TurningPoint reviews PA/MND requests in accordance with the clinical medical necessity criteria and guidelines adopted by Horizon BCBSNJ. An approved PA/MND does not supersede member benefits, and as such, is not a guarantee of payment for services provided.

Q6. What Horizon BCBSNJ plans/products are included in the scope of this program?
A6. This program applies to members enrolled in the following fully insured Horizon BCBSNJ plans/products:

• Advantage EPO
• Direct Access
• EPO
• HMO
• Indemnity
• OMNIASM Health Plans
• PPO
• POS
• SHBP/SEHBP plans are also included

You can look at the member’s ID card to determine whether the plan is self-insured Administrative Services Only (ASO) or fully insured. A self-insured ASO member ID card will state, “Horizon BCBSNJ provides administrative services only and does not assume any financial risk for claims.” A fully insured member’s ID card will not have that message. Please always verify member benefits, as it may be possible that the most current ID card is not presented at the time of service.

Q7. What plans/products are NOT included in the scope of this program?
A7. Members enrolled in the following plans/products are NOT included in the scope of this
program:

• Federal Employee Program® (FEP®)
• Medicare Advantage (including Braven Health℠ plans effective 1/1/2021)
• Medigap
• Horizon NJ Health
• Horizon NJ TotalCare (HMO SNP)
• Self-Insured ASO (Administrative Services Only) employer groups

You can look at the member’s ID card to determine whether the plan is self-insured Administrative Services Only (ASO) or fully insured. A self-insured ASO member ID card will state, “Horizon BCBSNJ provides administrative services only and does not assume any financial risk for claims.” A fully insured member’s ID card will not have that message. Please always verify member benefits, as it may be possible that the most current ID card is not presented at the time of service.

Q8. How can I check the benefits of my Horizon BCBSNJ patients?
A8. You may review member benefit information on NaviNet. Simply log in to NaviNet.net and select Horizon BCBSNJ from theMy Health Plans menu. Mouse over Eligibility & Benefits and selectEligibility & Benefits Inquiry. If you do not have access to NaviNet, you may obtain member benefit information by callingPhysician Services at 1-800-624-1110 Monday through Friday, between 8 a.m. and 5 p.m. Eastern Time (ET).

Q9. Are participating and nonparticipating health care professionals included in this program?
A9. Yes. Participating and nonparticipating health care professionals in and out of New Jersey and are included in the program.

Q11. What are the components of the Surgical and Implantable Device Management Program?
A11. Key components of this program include:

• Administrative tools that support an efficient MND review process and produce documentation that facilitates timely claims payment.
• Specialized “peer-to-peer” engagement that allows health care professionals to communicate with medical specialty physicians regarding PA/MND requests.
• Clinical support tools to assist in the tracking, monitoring and improvement of patient outcomes, education and care.
• Effective, evidence-based device/implant management that helps ensure clinically appropriate, high-quality, cost-effective device selection.
• Reporting and analytics that gives physicians and practice administrators feedback regarding their practice performance as compared to others in the medical community.

Q12. How can I find out more information about this program?
A12. For more information about the Surgical and Implantable Device Management Program, you can visit HorizonBlue.com/turningpoint or
https://www.myturningpoint-healthcare.com.

If you have questions, call TurningPoint at 1-833-436-4083, Monday through Friday, from
8 a.m. to 5 p.m., Eastern Time (ET), or email HorizonNJUM@turningpoint-healthcare.com.

Health Care Professionals
Q13.When should I request a PA/MND from TurningPoint?
A13. You should request a PA/MND review for any proposed course of treatment involving the specialized orthopedic surgeries included as part of this program (see question 4).

Obtaining an approved PA/MND from TurningPoint will ensure that the services in question will be considered medically necessary.

Services that TurningPoint deems not medically necessary as part of this review may not be eligible for coverage or payment by Horizon BCBSNJ. Horizon BCBSNJ reserves the right to adjust claims based on TurningPoint’s recommendations.

Q14. I submitted a PA/MND request. What will happen next?
A14. There are three possible outcomes as of a result of the PA/MND review:

1. Approved: The complete treatment requested meets the criteria for medical necessity.

2. Partial Approval: Only a part of the treatment requested is approved and the remainder is denied.

3. Denied: The complete treatment does not meet clinical criteria and is denied.

• For Inpatient Admissions: PA is required as determined by the member’s benefits.
• For Outpatient Services: PA is required as determined by the member’s benefits; where member benefits do not require a PA, pre- and post-service MND apply.

Q15. Which specialized orthopedic surgeries are included as part of this program?
A15. A list of the procedure codes of the specific specialized orthopedic surgeries included as part of this program is available. Please refer to question 4 or visit HorizonBlue.com/turningpoint.

Q16. How often is the list of specialized orthopedic surgeries updated?
A16. The list of codes included as part of this program is updated annually, or more frequently, if necessary. Before calling for a PA/MND request, visit HorizonBlue.com/turningpoint for the most updated listing. A notice will be posted regarding any changes to the list on HorizonBlue.com/providernews.

Q17. How can I obtain the orthopedic medical policy criteria and guidelines for members enrolled in plans that are included in this program?
A17. You can access the medical policy criteria and guidelines TurningPoint conducts PA/MND reviews as part of this program via NaviNet. Practices that do not have access to NaviNet, may request access to TurningPoint’s web portal by calling TurningPoint at 1-833-436-4083, weekdays, between 8 a.m. and 5 p.m., ET.

Q18. Where can I find Horizon BCBSNJ’s medical policy criteria and guidelines for orthopedic services located for members enrolled in plans that are not included in the program?
A18. Horizon BCBSNJ’s medical policy criteria and guidelines for orthopedic services for members enrolled in plans that are not included in this program can be accessed by visiting HorizonBlue.com/medicalpolicy.

Prior Authorization/Medical Necessity Determination (PA/MND)

Q20. When should a health care professional obtain aPA/MND?
A20. A health care professional should request a PA/MND review upon determining the patient’s treatment plan includes any of the specialty orthopedic surgeries included within this program. It’s important that an approved PA/MND is obtained prior to delivery of the services to ensure coverage.

Services that TurningPoint deems not medically necessary as part of this review may not be eligible for coverage or payment by Horizon BCBSNJ. Horizon BCBSNJ reserves the right to adjust claims based on TurningPoint’s recommendations.

Q21. How does a health care professional initiate a PA/MND?
A21. A health care professional can initiate a PA/MND by one of the following methods:

• Health care professionals may log on to NaviNet to initiate a PA/MND. Health care professionals who do not have access to NaviNet may submit a request via TurningPoint’s web portal at https://www.myturningpoint-healthcare.com. You must register to obtain access credentials to TurningPoint’s web portal by calling TurningPoint at 1-833-436-4083, weekdays, between 8 a.m. and 5 p.m., ET.
• • Health care professionals may also call TurningPoint at 1-833-436-4083. For urgent requests, you must inform the Call Center Specialist that the request is URGENT to receive an expedited response.
• If you call Horizon BCBSNJ’s prior authorization line regarding one of the procedures within the Surgical and Implantable Device Management Program, you will be transferred to TurningPoint for their PA/MND review of the specialized orthopedic surgery being requested.

Q22. What is the best method for requesting a PA/MND?
A22. The quickest and most efficient method to submit a PA/MND is through NaviNet. Health care professionals who do not have access to NaviNet, may submit a request via TurningPoint’s web portal at https://www.myturningpoint-healthcare.com.

You may also call TurningPoint at 1-833-436-4083.TurningPoint medical professionals are on call 24 hours a day, seven days a week at the same phone number.

• The on-call staff member will respond to cases involving urgent care usually within an hour.
• TurningPoint will respond to cases involving non-urgent care within one business day.
• All calls left with the answering service after hours will be addressed within one business day. All emails also will be addressed within one business day.

Q24. What is the ordering/rendering health care professional’s responsibility?
A24. The ordering/rendering health care professional must obtain the PA/MND and supply all of the demographic and clinical information. If a PA/MND is not obtained prior to rendering services, claim payment may be delayed or denied pending completion of a post-service MND review. If the rendering health care professional, who is not the ordering health care professional, calls TurningPoint to initiate a PA/MND, TurningPoint will contact the ordering health care professional to obtain the necessary clinical information.

The clinical information must be provided regardless of whether the ordering and the rendering health care professional are the same.

Q25. If a co-surgeon is required for a planned specialized orthopedic surgery procedure, what do I need to do?
A25. The rendering health care professional MUST indicate if an assistant or co‐surgeon is required for the requested specialized orthopedic surgery. The health care professional must provide TurningPoint with the assistant or co-surgeon’s name, Tax Identification Number (TIN) and Horizon BCBSNJ participation status.

Horizon BCBSNJ expects its participating primary surgeons to use the services of an assistant surgeon participating in our network when they are medically necessary in the performance of any specialized orthopedic surgery. In the event that a nonparticipating assistant surgeon is used, you must inform the member of the financial impact it may have on the member’s out-of-pocket costs.

Q26. How will TurningPoint notify me about the PA/MND determination?
A26. Approved determination: TurningPoint will call the requesting practitioner’s office to advise them of an approved determination made on the request. The physician, facility and member will receive an approval letter regarding the PA/MND request.

Adverse determination: TurningPoint will call the requesting physician’s office to explain the rationale for the denial. TurningPoint offers the physician the opportunity to send in additional information for reconsideration, or the opportunity to schedule a
peer-to-peer conversation with the TurningPoint reviewer to discuss the denial.

Following this call, if the determination has not been changed as a result of the reconsideration, TurningPoint will send an adverse determination notification letter to the provider, member and facility, (where appropriate) detailing the rationale for the denied PA/MND. You can check status of the PA/MND determination by calling TurningPoint at 1-833-436-4083.

Q27. May I schedule a peer-to-peer conversation to discuss an adverse determination?
A27. Yes, TurningPoint offers physicians the opportunity to call TurningPoint at
1-833-436-4083 to schedule a peer-to-peer conversation with the TurningPoint reviewer to discuss an adverse determination.

Q28. Is an approved PA/MND review a guarantee of payment?
A28. No. An approved PA/MND is not a guarantee of payment. Claims submitted for these services will also be subject, but not limited to, the following:

• Member eligibility at the time services are provided

• Benefit limitations and/or exclusions

• Appropriateness of codes billed

• Horizon BCBSNJ’s claims reimbursement policies

Q29. Are clinical trials part of this program?
A29. No. Clinical trials are not a part of this program. TurningPoint will handle PA/MND requests for investigational clinical trials if the member is participating in a national clinic trial with the exception of cancer clinical trials. PA/MND for cancer clinical trials will be handled by Horizon BCBSNJ. Please call Horizon BCBSNJ’s Complex Case Management department at 1-888-621-5894, option 2 for clinical trials.

Q30. What is the time frame for TurningPoint to render a PA/MND decision?
A30. Non-urgent PA/MND requests will be completed as soon as possiblebased on the urgency of the case, but no later than three business days from receipt of all required clinical information. If medical information that is critical to determine medical necessity under our medical policy requirements is missing, TurningPoint will contact the practice to obtain the information needed to complete the review. The determination will be made no later than
15 days from receipt of the necessary clinical information. Urgent PA/MND requests will be completed as soon as possible based on the urgency of the case, but no later than
72 hours from receipt of the request. Please refer to question 24 for the minimum information, which should be presented when submitting a PA/MND request.

Q31. How can I check the status of a PA/MND?
A31. The status of a PA/MND may be reviewed by one of the following methods:

• You may log on to NaviNet to submit a request.
• If you do not have access to NaviNet, you can submit a request via TurningPoint’s web portal at https://www.myturningpoint-healthcare.com. You must register to obtain access credentials by calling TurningPoint at 1-833-436-4083, weekdays, between 8 a.m. and 5 p.m., ET.
• Call TurningPoint at 1-833-436-4083 to confirm the status of a PA/MND.

Q32. Does a PA/MND approval number expire?
A32. Yes. An approved PA/MND is valid for 90 days from the date of approval.

Q33. If I want to modify a request BEFORE the procedure occurs, do I need to notify TurningPoint to update the PA/MND?A33. Yes. Call TurningPoint to notify them of any modification to your request prior to the procedure occurring. Modifications to a PA/MND request may be made up to one day before the date of service for the surgical procedure. TurningPoint may require a new review of the case for medical necessity and/or clinical appropriateness of the change depending on what change is being requested.

Q34. If I need to modify a request, or if there is a change in the surgical plan DURING the procedure, should I notify TurningPoint to update the PA/MND?
A34. No. If you received an approved PA/MND and the surgical plan changes during the procedure, submit the claim as per normal Horizon BCBSNJ policy. If additional information is required to perform a post-service medical necessity review because of the change, TurningPoint will contact you for the additional clinical information needed as part of Horizon BCBSNJ’s claims/claims appeals process.

Q35. What if a member is scheduled for a specialized orthopedic surgery and is admitted for the procedure, but does not have a PA/MND?
A35. If a Notice of Admission (NOA) is received, and there is no record of an approved PA/MND by TurningPoint on file, Horizon BCBSNJ will review the case as an inpatient authorization request and notify TurningPoint of the admission via secure email. TurningPoint will then contact the health care professionalto obtain the appropriate medical records to perform a post service medical necessity review for the surgery.

Q36. What happens if TurningPoint receives a PA/MND request that is not within the scope of the Surgical and Implantable Device Management Program?
A36. If the request is determined to be out of scope, TurningPoint will forward the request to the Horizon BCBSNJ’s Utilization Management review team.

Q37. Does TurningPoint consider the site of care within its medical necessity criteria when reviewing authorization requests?
A37. Yes. TurningPoint will review the proposed site of care, (i.e. in-patient vs. out-patient), for certain procedures whichare requested to determine if it is medically appropriate to perform the procedure in the requested setting at the same facility. This approach aligns with CMS guidelines and generally accepted standards of medical practice. Should any issues or complications arise in the course of the patient’s procedure that is performed as an
out-patient, and an inpatient stay is then needed, the facility can request approval for that admission by contactingHorizon BCBSNJ’s Concurrent Review Department.

Claims

Q38. Should claims for services included as part of this program be submitted to TurningPoint?
A38. No. Claims should be submitted to Horizon BCBSNJ. Claims submitted without an approved PA/MND review may be denied.

Appeals

Q39.How can I appeal denied PA/MND requests?
A39. TurningPoint will make a clinical determination for Level 1 medical necessity appeals. TurningPoint will send an appeal determination letter to the member and physician, update the authorization record and advise Horizon BCBSNJ of the review outcome. If the appeal is upheld, the appeal determination letter will include information regarding further appeal rights that are available.

For post-service medical necessity appeal received directly by Horizon BCBSNJ, Horizon BCBSNJ will confirm if TurningPoint conducted a pre-service review. If the case is denied due to an authorization/medical necessity pre-service review performed by TurningPoint, then Horizon BCBSNJ will redirect the appeal to TurningPoint for Level 1 appeal review.

Q40. How can I dispute a PA/MNDdenial?
A40. Generally, a health care professional may dispute a denial that was based on medical necessity by seeking an appeal by:

• Calling TurningPoint at 1-833-436-4083, or
• Submitting written appeals to:
  1Attn: Appeals Dept.
  TurningPoint Healthcare Solutions, LLC
  1000 Primera Blvd.
  Suite 3160
  Lake Mary, FL 32746

Q41. How can I dispute a denial that is not related to a PA/MND?
A41. You may dispute a denied claims determination that is not related to a PA/MND (a decision not based on medical judgment) by calling Horizon BCBSNJ’s Physician Services at
1-­800-­624--1110 orFacility Services at 1-­888-­666-­2535,weekdays, 8 a.m. to 5 p.m., ET.

Q42. Who can a health care professional contact for more information about a PA/MND appeal they submitted?
A42. For an appeal involving a PA/MND, they should call TurningPoint at 1-833-436-4083. For a claim appeal not involving medical judgment, call Horizon BCBSNJ’s Physician Services at 1-800-624-1110.

Ancillary/Facility

Q43. What is the ordering/rendering health care professional’s responsibility? What happens if the surgeon performing the procedure does not confirm that an approved PA/MND is obtained from TurningPoint?
A43. The ordering/rendering health care professional must obtain the PA/MND and supply all of the demographic and clinical information. If a PA/MND is not obtained prior to rendering services, claim payment may be delayed or denied pending completion of a post-service MND review. If the rendering health care professional, who is not the ordering health care professional, calls TurningPoint to initiate a PA/MND, TurningPoint will contact the ordering health care professional to obtain the necessary clinical information. The clinical information must be provided regardless of whether the ordering and the rendering health care professional are the same.

Q44. Will there be any financial impact to the facility if a device other than what was authorized by TurningPoint is used?
A44. The financial impact of using a device other than what was authorized by TurningPoint depends on the site of service.

INPATIENT FACILITY: There will be no financial impact if a device other than what was originally authorized by TurningPoint is used during a surgery performed in an inpatient hospital setting.

OUTPATIENT or AMBULATORY SURGERY CENTER (ASC): If a different device other than what was originally authorized by TurningPoint is used during a surgery performed in an outpatient or ASC setting, the device will be denied for no authorization. This situation would only occur if an authorization is required based on the member’s benefits in an outpatient or ASC setting.

If a device is changed, TurningPoint should be made aware of the change. The device must be FDA approved and meet TurningPoint’s medical necessity criteria for the clinical application. We encourage all facilities to verify what procedure and device has been approved by contacting the rendering physician’s office or TurningPoint BEFORE the procedure.

Q45. What happens to the facility claim if the procedure is performed without a PA/MND approval?
A45. If a PA/MND is not obtained prior to rendering services, facility claim payment may be delayed or denied pending completion of a post-service MND review.

If TurningPoint’s post-service review determines that a procedure is not medically necessary, the professional and facility claims for or related to that procedure will be subject to denial. Participating physicians and facilities may not bill Horizon BCBSNJ members for any such denied amounts.

To ensure there will be no delayed or denied claim payment, facilities should check with the ordering/rendering health care professional or TurningPoint BEFORE the procedure to ensure that the procedure and the device used (if applicable) has been reviewed and approved.

The PA/MND requirement as part of this program does not impact/change a hospital’s existing authorization requirement for elective inpatient stays.

Q46. What if the physician changes the surgical plan or device based on the clinical condition during the surgery? Will it impact the facility claim?
A46.If the physician receives an approved PA/MND and the surgical plan or device is changed during the procedure, the physician/facility claim should be submitted according to Horizon BCBSNJ’s normal processes. If additional information is required to perform a post-service medical necessity review as a result of a change in information or surgical device, TurningPoint will contact the physician/facility for additional clinical information as part of Horizon BCBSNJ’s claims/claims appeals process. If there is a change to the device, TurningPoint will also review to ensure that the changed device is FDA approved for the clinical application.

An approved authorization is not a guarantee of payment. Payment is subject to member eligibility and all member and group benefit limitations, conditions and exclusions in effect at the time of the surgery, as well as Horizon BCBSNJ reimbursement policies.

Q47. Who is responsible to determine whether the procedure and device were reviewed and approved by TurningPoint?
A47.TurningPoint will notify the physician of the approved procedure and device (as applicable). Physicians are instructed to inform the facility/operation room about the approval of the procedure/device to be used at the time of scheduling.

Rendering facilities are strongly encouraged to confirm the status of a PA/MND BEFORE a procedure is performed. Facilities may confirm the status of a PA/MND with the rendering physician, online or with TurningPoint as noted below.

• You may log on to NaviNet to confirm the status of a PA/MND request.
• If you do not have access to NaviNet, you can confirm the status of a PA/MND request at https://www.myturningpoint-healthcare.com. To register for access to TurningPoint’s web portal, please call TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., ET.
• You may also call TurningPoint at 1-833-436-4083 to confirm the status of a PA/MND and to provide a specific area and contact within the facility to receive future approvals and denials.

Q48. If a device is not approved, will the surgery need to be canceled?
A48. The program is designed to offer PA/MND review in advance of a planned date of surgery to ensure coverage. Procedures that do not meet the medical necessity criteria, or if the physician selects a non-FDA approved device, will be denied.

Use of theMember Attestation for Use of an Out-of-Network Provider form

Q49.When should members complete the Member Attestation for Use of an
Out-of-Network Provider form?
A49. The member should complete the Member Attestation for Use of an Out-of-Network Provider form if he/she is enrolled in a Horizon BCBSNJ plan that includes out-of-network benefits, and an out-of-network doctor, facility and/or other health care professional has been selected to participate in his/her upcoming procedure. This form is ONLY to be used for patients enrolled in Horizon BCBSNJ plans that include out-of-network benefits.

The Member Attestation for Use of an Out-of-Network Provider form is NOT to be used for services to be provided to members enrolled in plans that do not include out-of-network benefits (including, but not limited to, Horizon HMO plans, Horizon EPO plans, OMNIASM Health Plans and Medicare Advantage HMO plans).

Q50.Why do members need to complete the Member Attestation for Use of an
Out-of-Network Provider form?
A50. Horizon BCBSNJ encourages the use of in-network doctors, facilities and other health care professionals to help members get the most out of their benefits and to help lower their out-of-pocket costs. If an out-of-network doctor, facility or other health care professional is chosen to participate in a procedure, it’s important that the member understands the financial impact of this decision.

When a member uses out-of-network benefits, in addition to being responsible for any out-of-network cost-sharing amounts (copayments, deductible and coinsurance amounts, as applicable), the member is also responsible for the difference between Horizon BCBSNJ’s allowance for eligible services and the out-of-network health care professionals’ total billed charges.

Q51.How will members be made aware thatthe Member Attestation for Use of an
Out-of-Network Provider form should be completed?
A51. When TurningPoint receives a request for the pre-approval (or prior authorization) of services to be rendered by an out-of-network doctor, facility and/or other health care professional, the member will receive a letter requesting that the Member Attestation for Use of an Out-of-Network Provider form be completed. A copy of the form will be included. As always, we encourage members to use participating doctors, facilities and health care professionals to help reduce their out-of-pocket costs.

Q1. What is the Surgical and Implantable Device Management Program?
A1. Horizon BCBSNJ’s Surgical and Implantable Device Management Program, managed in coordination with TurningPoint, integrates evidence-based utilization management guidelines with clinical best practices, specialized peer-to-peer engagement, claims review and management, and advanced reporting and analytics to promote the overall health management of impacted members.

Q2. What is the relationship between Horizon BCBSNJ and TurningPoint?
A2. Horizon BCBSNJ has contracted TurningPoint for PA/MND reviews of select orthopedic surgeries requested by participating and nonparticipating physicians. It aims to help reduce surgical treatment variability, promote safety, improve the quality of care and outcomes and encourage patient support.

Q3. What services does TurningPoint perform as part of the Surgical and Implantable Device Management Program?
A3. TurningPoint provides utilization management (UM) reviews, First Level UM appeals processing, claim reviews and UM-related customer service support for certain specialized orthopedic surgeries (see question 4).

Q4. For what procedures/services does TurningPoint perform PA/MNDs as part of this program?
A4. TurningPoint performs PA/MND reviews for medical necessity and appropriate length of stay (when applicable) for:

Q5. How does TurningPoint manage the specialized orthopedic surgeries?
A5. TurningPoint reviews PA/MND requests in accordance with the clinical medical necessity criteria and guidelines adopted by Horizon BCBSNJ. An approved PA/MND does not supersede member benefits, and as such, is not a guarantee of payment for services provided.

Q6. What Horizon BCBSNJ plans/products are included in the scope of this program?
A6. This program applies to members enrolled in the following fully insured Horizon BCBSNJ plans/products:

• Advantage EPO
• Direct Access
• EPO
• HMO
• Indemnity
• OMNIASM Health Plans
• PPO
• POS
• SHBP/SEHBP plans are also included

You can look at the member’s ID card to determine whether the plan is self-insured Administrative Services Only (ASO) or fully insured. A self-insured ASO member ID card will state, “Horizon BCBSNJ provides administrative services only and does not assume any financial risk for claims.” A fully insured member’s ID card will not have that message. Please always verify member benefits, as it may be possible that the most current ID card is not presented at the time of service.

Q7. What plans/products are NOT included in the scope of this program?
A7. Members enrolled in the following plans/products are NOT included in the scope of this
program:

• Federal Employee Program® (FEP®)
• Medicare Advantage (including Braven Health℠ plans effective 1/1/2021)
• Medigap
• Horizon NJ Health
• Horizon NJ TotalCare (HMO SNP)
• Self-Insured ASO (Administrative Services Only) employer groups

You can look at the member’s ID card to determine whether the plan is self-insured Administrative Services Only (ASO) or fully insured. A self-insured ASO member ID card will state, “Horizon BCBSNJ provides administrative services only and does not assume any financial risk for claims.” A fully insured member’s ID card will not have that message. Please always verify member benefits, as it may be possible that the most current ID card is not presented at the time of service.

Q8. How can I check the benefits of my Horizon BCBSNJ patients?
A8. You may review member benefit information on NaviNet. Simply log in to NaviNet.net and select Horizon BCBSNJ from theMy Health Plans menu. Mouse over Eligibility & Benefits and selectEligibility & Benefits Inquiry. If you do not have access to NaviNet, you may obtain member benefit information by callingPhysician Services at 1-800-624-1110 Monday through Friday, between 8 a.m. and 5 p.m. Eastern Time (ET).

Q9. Are participating and nonparticipating health care professionals included in this program?
A9. Yes. Participating and nonparticipating health care professionals in and out of New Jersey and are included in the program.

Q11. What are the components of the Surgical and Implantable Device Management Program?
A11. Key components of this program include:

• Administrative tools that support an efficient MND review process and produce documentation that facilitates timely claims payment.
• Specialized “peer-to-peer” engagement that allows health care professionals to communicate with medical specialty physicians regarding PA/MND requests.
• Clinical support tools to assist in the tracking, monitoring and improvement of patient outcomes, education and care.
• Effective, evidence-based device/implant management that helps ensure clinically appropriate, high-quality, cost-effective device selection.
• Reporting and analytics that gives physicians and practice administrators feedback regarding their practice performance as compared to others in the medical community.

Q12. How can I find out more information about this program?
A12. For more information about the Surgical and Implantable Device Management Program, you can visit HorizonBlue.com/turningpoint or
https://www.myturningpoint-healthcare.com.

If you have questions, call TurningPoint at 1-833-436-4083, Monday through Friday, from
8 a.m. to 5 p.m., Eastern Time (ET), or email HorizonNJUM@turningpoint-healthcare.com.

Health Care Professionals
Q13.When should I request a PA/MND from TurningPoint?
A13. You should request a PA/MND review for any proposed course of treatment involving the specialized orthopedic surgeries included as part of this program (see question 4).

Obtaining an approved PA/MND from TurningPoint will ensure that the services in question will be considered medically necessary.

Services that TurningPoint deems not medically necessary as part of this review may not be eligible for coverage or payment by Horizon BCBSNJ. Horizon BCBSNJ reserves the right to adjust claims based on TurningPoint’s recommendations.

Q14. I submitted a PA/MND request. What will happen next?
A14. There are three possible outcomes as of a result of the PA/MND review:

1. Approved: The complete treatment requested meets the criteria for medical necessity.

2. Partial Approval: Only a part of the treatment requested is approved and the remainder is denied.

3. Denied: The complete treatment does not meet clinical criteria and is denied.

• For Inpatient Admissions: PA is required as determined by the member’s benefits.
• For Outpatient Services: PA is required as determined by the member’s benefits; where member benefits do not require a PA, pre- and post-service MND apply.

Q15. Which specialized orthopedic surgeries are included as part of this program?
A15. A list of the procedure codes of the specific specialized orthopedic surgeries included as part of this program is available. Please refer to question 4 or visit HorizonBlue.com/turningpoint.

Q16. How often is the list of specialized orthopedic surgeries updated?
A16. The list of codes included as part of this program is updated annually, or more frequently, if necessary. Before calling for a PA/MND request, visit HorizonBlue.com/turningpoint for the most updated listing. A notice will be posted regarding any changes to the list on HorizonBlue.com/providernews.

Q17. How can I obtain the orthopedic medical policy criteria and guidelines for members enrolled in plans that are included in this program?
A17. You can access the medical policy criteria and guidelines TurningPoint conducts PA/MND reviews as part of this program via NaviNet. Practices that do not have access to NaviNet, may request access to TurningPoint’s web portal by calling TurningPoint at 1-833-436-4083, weekdays, between 8 a.m. and 5 p.m., ET.

Q18. Where can I find Horizon BCBSNJ’s medical policy criteria and guidelines for orthopedic services located for members enrolled in plans that are not included in the program?
A18. Horizon BCBSNJ’s medical policy criteria and guidelines for orthopedic services for members enrolled in plans that are not included in this program can be accessed by visiting HorizonBlue.com/medicalpolicy.

Prior Authorization/Medical Necessity Determination (PA/MND)

Q20. When should a health care professional obtain aPA/MND?
A20. A health care professional should request a PA/MND review upon determining the patient’s treatment plan includes any of the specialty orthopedic surgeries included within this program. It’s important that an approved PA/MND is obtained prior to delivery of the services to ensure coverage.

Services that TurningPoint deems not medically necessary as part of this review may not be eligible for coverage or payment by Horizon BCBSNJ. Horizon BCBSNJ reserves the right to adjust claims based on TurningPoint’s recommendations.

Q21. How does a health care professional initiate a PA/MND?
A21. A health care professional can initiate a PA/MND by one of the following methods:

• Health care professionals may log on to NaviNet to initiate a PA/MND. Health care professionals who do not have access to NaviNet may submit a request via TurningPoint’s web portal at https://www.myturningpoint-healthcare.com. You must register to obtain access credentials to TurningPoint’s web portal by calling TurningPoint at 1-833-436-4083, weekdays, between 8 a.m. and 5 p.m., ET.
• • Health care professionals may also call TurningPoint at 1-833-436-4083. For urgent requests, you must inform the Call Center Specialist that the request is URGENT to receive an expedited response.
• If you call Horizon BCBSNJ’s prior authorization line regarding one of the procedures within the Surgical and Implantable Device Management Program, you will be transferred to TurningPoint for their PA/MND review of the specialized orthopedic surgery being requested.

Q22. What is the best method for requesting a PA/MND?
A22. The quickest and most efficient method to submit a PA/MND is through NaviNet. Health care professionals who do not have access to NaviNet, may submit a request via TurningPoint’s web portal at https://www.myturningpoint-healthcare.com.

You may also call TurningPoint at 1-833-436-4083.TurningPoint medical professionals are on call 24 hours a day, seven days a week at the same phone number.

• The on-call staff member will respond to cases involving urgent care usually within an hour.
• TurningPoint will respond to cases involving non-urgent care within one business day.
• All calls left with the answering service after hours will be addressed within one business day. All emails also will be addressed within one business day.

Q24. What is the ordering/rendering health care professional’s responsibility?
A24. The ordering/rendering health care professional must obtain the PA/MND and supply all of the demographic and clinical information. If a PA/MND is not obtained prior to rendering services, claim payment may be delayed or denied pending completion of a post-service MND review. If the rendering health care professional, who is not the ordering health care professional, calls TurningPoint to initiate a PA/MND, TurningPoint will contact the ordering health care professional to obtain the necessary clinical information.

The clinical information must be provided regardless of whether the ordering and the rendering health care professional are the same.

Q25. If a co-surgeon is required for a planned specialized orthopedic surgery procedure, what do I need to do?
A25. The rendering health care professional MUST indicate if an assistant or co‐surgeon is required for the requested specialized orthopedic surgery. The health care professional must provide TurningPoint with the assistant or co-surgeon’s name, Tax Identification Number (TIN) and Horizon BCBSNJ participation status.

Horizon BCBSNJ expects its participating primary surgeons to use the services of an assistant surgeon participating in our network when they are medically necessary in the performance of any specialized orthopedic surgery. In the event that a nonparticipating assistant surgeon is used, you must inform the member of the financial impact it may have on the member’s out-of-pocket costs.

Q26. How will TurningPoint notify me about the PA/MND determination?
A26. Approved determination: TurningPoint will call the requesting practitioner’s office to advise them of an approved determination made on the request. The physician, facility and member will receive an approval letter regarding the PA/MND request.

Adverse determination: TurningPoint will call the requesting physician’s office to explain the rationale for the denial. TurningPoint offers the physician the opportunity to send in additional information for reconsideration, or the opportunity to schedule a
peer-to-peer conversation with the TurningPoint reviewer to discuss the denial.

Following this call, if the determination has not been changed as a result of the reconsideration, TurningPoint will send an adverse determination notification letter to the provider, member and facility, (where appropriate) detailing the rationale for the denied PA/MND. You can check status of the PA/MND determination by calling TurningPoint at 1-833-436-4083.

Q27. May I schedule a peer-to-peer conversation to discuss an adverse determination?
A27. Yes, TurningPoint offers physicians the opportunity to call TurningPoint at
1-833-436-4083 to schedule a peer-to-peer conversation with the TurningPoint reviewer to discuss an adverse determination.

Q28. Is an approved PA/MND review a guarantee of payment?
A28. No. An approved PA/MND is not a guarantee of payment. Claims submitted for these services will also be subject, but not limited to, the following:

• Member eligibility at the time services are provided

• Benefit limitations and/or exclusions

• Appropriateness of codes billed

• Horizon BCBSNJ’s claims reimbursement policies

Q29. Are clinical trials part of this program?
A29. No. Clinical trials are not a part of this program. TurningPoint will handle PA/MND requests for investigational clinical trials if the member is participating in a national clinic trial with the exception of cancer clinical trials. PA/MND for cancer clinical trials will be handled by Horizon BCBSNJ. Please call Horizon BCBSNJ’s Complex Case Management department at 1-888-621-5894, option 2 for clinical trials.

Q30. What is the time frame for TurningPoint to render a PA/MND decision?
A30. Non-urgent PA/MND requests will be completed as soon as possiblebased on the urgency of the case, but no later than three business days from receipt of all required clinical information. If medical information that is critical to determine medical necessity under our medical policy requirements is missing, TurningPoint will contact the practice to obtain the information needed to complete the review. The determination will be made no later than
15 days from receipt of the necessary clinical information. Urgent PA/MND requests will be completed as soon as possible based on the urgency of the case, but no later than
72 hours from receipt of the request. Please refer to question 24 for the minimum information, which should be presented when submitting a PA/MND request.

Q31. How can I check the status of a PA/MND?
A31. The status of a PA/MND may be reviewed by one of the following methods:

• You may log on to NaviNet to submit a request.
• If you do not have access to NaviNet, you can submit a request via TurningPoint’s web portal at https://www.myturningpoint-healthcare.com. You must register to obtain access credentials by calling TurningPoint at 1-833-436-4083, weekdays, between 8 a.m. and 5 p.m., ET.
• Call TurningPoint at 1-833-436-4083 to confirm the status of a PA/MND.

Q32. Does a PA/MND approval number expire?
A32. Yes. An approved PA/MND is valid for 90 days from the date of approval.

Q33. If I want to modify a request BEFORE the procedure occurs, do I need to notify TurningPoint to update the PA/MND?A33. Yes. Call TurningPoint to notify them of any modification to your request prior to the procedure occurring. Modifications to a PA/MND request may be made up to one day before the date of service for the surgical procedure. TurningPoint may require a new review of the case for medical necessity and/or clinical appropriateness of the change depending on what change is being requested.

Q34. If I need to modify a request, or if there is a change in the surgical plan DURING the procedure, should I notify TurningPoint to update the PA/MND?
A34. No. If you received an approved PA/MND and the surgical plan changes during the procedure, submit the claim as per normal Horizon BCBSNJ policy. If additional information is required to perform a post-service medical necessity review because of the change, TurningPoint will contact you for the additional clinical information needed as part of Horizon BCBSNJ’s claims/claims appeals process.

Q35. What if a member is scheduled for a specialized orthopedic surgery and is admitted for the procedure, but does not have a PA/MND?
A35. If a Notice of Admission (NOA) is received, and there is no record of an approved PA/MND by TurningPoint on file, Horizon BCBSNJ will review the case as an inpatient authorization request and notify TurningPoint of the admission via secure email. TurningPoint will then contact the health care professionalto obtain the appropriate medical records to perform a post service medical necessity review for the surgery.

Q36. What happens if TurningPoint receives a PA/MND request that is not within the scope of the Surgical and Implantable Device Management Program?
A36. If the request is determined to be out of scope, TurningPoint will forward the request to the Horizon BCBSNJ’s Utilization Management review team.

Q37. Does TurningPoint consider the site of care within its medical necessity criteria when reviewing authorization requests?
A37. Yes. TurningPoint will review the proposed site of care, (i.e. in-patient vs. out-patient), for certain procedures whichare requested to determine if it is medically appropriate to perform the procedure in the requested setting at the same facility. This approach aligns with CMS guidelines and generally accepted standards of medical practice. Should any issues or complications arise in the course of the patient’s procedure that is performed as an
out-patient, and an inpatient stay is then needed, the facility can request approval for that admission by contactingHorizon BCBSNJ’s Concurrent Review Department.

Claims

Q38. Should claims for services included as part of this program be submitted to TurningPoint?
A38. No. Claims should be submitted to Horizon BCBSNJ. Claims submitted without an approved PA/MND review may be denied.

Appeals

Q39.How can I appeal denied PA/MND requests?
A39. TurningPoint will make a clinical determination for Level 1 medical necessity appeals. TurningPoint will send an appeal determination letter to the member and physician, update the authorization record and advise Horizon BCBSNJ of the review outcome. If the appeal is upheld, the appeal determination letter will include information regarding further appeal rights that are available.

For post-service medical necessity appeal received directly by Horizon BCBSNJ, Horizon BCBSNJ will confirm if TurningPoint conducted a pre-service review. If the case is denied due to an authorization/medical necessity pre-service review performed by TurningPoint, then Horizon BCBSNJ will redirect the appeal to TurningPoint for Level 1 appeal review.

Q40. How can I dispute a PA/MNDdenial?
A40. Generally, a health care professional may dispute a denial that was based on medical necessity by seeking an appeal by:

• Calling TurningPoint at 1-833-436-4083, or
• Submitting written appeals to:
  1Attn: Appeals Dept.
  TurningPoint Healthcare Solutions, LLC
  1000 Primera Blvd.
  Suite 3160
  Lake Mary, FL 32746

Q41. How can I dispute a denial that is not related to a PA/MND?
A41. You may dispute a denied claims determination that is not related to a PA/MND (a decision not based on medical judgment) by calling Horizon BCBSNJ’s Physician Services at
1-­800-­624--1110 orFacility Services at 1-­888-­666-­2535,weekdays, 8 a.m. to 5 p.m., ET.

Q42. Who can a health care professional contact for more information about a PA/MND appeal they submitted?
A42. For an appeal involving a PA/MND, they should call TurningPoint at 1-833-436-4083. For a claim appeal not involving medical judgment, call Horizon BCBSNJ’s Physician Services at 1-800-624-1110.

Ancillary/Facility

Q43. What is the ordering/rendering health care professional’s responsibility? What happens if the surgeon performing the procedure does not confirm that an approved PA/MND is obtained from TurningPoint?
A43. The ordering/rendering health care professional must obtain the PA/MND and supply all of the demographic and clinical information. If a PA/MND is not obtained prior to rendering services, claim payment may be delayed or denied pending completion of a post-service MND review. If the rendering health care professional, who is not the ordering health care professional, calls TurningPoint to initiate a PA/MND, TurningPoint will contact the ordering health care professional to obtain the necessary clinical information. The clinical information must be provided regardless of whether the ordering and the rendering health care professional are the same.

Q44. Will there be any financial impact to the facility if a device other than what was authorized by TurningPoint is used?
A44. The financial impact of using a device other than what was authorized by TurningPoint depends on the site of service.

INPATIENT FACILITY: There will be no financial impact if a device other than what was originally authorized by TurningPoint is used during a surgery performed in an inpatient hospital setting.

OUTPATIENT or AMBULATORY SURGERY CENTER (ASC): If a different device other than what was originally authorized by TurningPoint is used during a surgery performed in an outpatient or ASC setting, the device will be denied for no authorization. This situation would only occur if an authorization is required based on the member’s benefits in an outpatient or ASC setting.

If a device is changed, TurningPoint should be made aware of the change. The device must be FDA approved and meet TurningPoint’s medical necessity criteria for the clinical application. We encourage all facilities to verify what procedure and device has been approved by contacting the rendering physician’s office or TurningPoint BEFORE the procedure.

Q45. What happens to the facility claim if the procedure is performed without a PA/MND approval?
A45. If a PA/MND is not obtained prior to rendering services, facility claim payment may be delayed or denied pending completion of a post-service MND review.

If TurningPoint’s post-service review determines that a procedure is not medically necessary, the professional and facility claims for or related to that procedure will be subject to denial. Participating physicians and facilities may not bill Horizon BCBSNJ members for any such denied amounts.

To ensure there will be no delayed or denied claim payment, facilities should check with the ordering/rendering health care professional or TurningPoint BEFORE the procedure to ensure that the procedure and the device used (if applicable) has been reviewed and approved.

The PA/MND requirement as part of this program does not impact/change a hospital’s existing authorization requirement for elective inpatient stays.

Q46. What if the physician changes the surgical plan or device based on the clinical condition during the surgery? Will it impact the facility claim?
A46.If the physician receives an approved PA/MND and the surgical plan or device is changed during the procedure, the physician/facility claim should be submitted according to Horizon BCBSNJ’s normal processes. If additional information is required to perform a post-service medical necessity review as a result of a change in information or surgical device, TurningPoint will contact the physician/facility for additional clinical information as part of Horizon BCBSNJ’s claims/claims appeals process. If there is a change to the device, TurningPoint will also review to ensure that the changed device is FDA approved for the clinical application.

An approved authorization is not a guarantee of payment. Payment is subject to member eligibility and all member and group benefit limitations, conditions and exclusions in effect at the time of the surgery, as well as Horizon BCBSNJ reimbursement policies.

Q47. Who is responsible to determine whether the procedure and device were reviewed and approved by TurningPoint?
A47.TurningPoint will notify the physician of the approved procedure and device (as applicable). Physicians are instructed to inform the facility/operation room about the approval of the procedure/device to be used at the time of scheduling.

Rendering facilities are strongly encouraged to confirm the status of a PA/MND BEFORE a procedure is performed. Facilities may confirm the status of a PA/MND with the rendering physician, online or with TurningPoint as noted below.

• You may log on to NaviNet to confirm the status of a PA/MND request.
• If you do not have access to NaviNet, you can confirm the status of a PA/MND request at https://www.myturningpoint-healthcare.com. To register for access to TurningPoint’s web portal, please call TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., ET.
• You may also call TurningPoint at 1-833-436-4083 to confirm the status of a PA/MND and to provide a specific area and contact within the facility to receive future approvals and denials.

Q48. If a device is not approved, will the surgery need to be canceled?
A48. The program is designed to offer PA/MND review in advance of a planned date of surgery to ensure coverage. Procedures that do not meet the medical necessity criteria, or if the physician selects a non-FDA approved device, will be denied.

Use of theMember Attestation for Use of an Out-of-Network Provider form

Q49.When should members complete the Member Attestation for Use of an
Out-of-Network Provider form?
A49. The member should complete the Member Attestation for Use of an Out-of-Network Provider form if he/she is enrolled in a Horizon BCBSNJ plan that includes out-of-network benefits, and an out-of-network doctor, facility and/or other health care professional has been selected to participate in his/her upcoming procedure. This form is ONLY to be used for patients enrolled in Horizon BCBSNJ plans that include out-of-network benefits.

The Member Attestation for Use of an Out-of-Network Provider form is NOT to be used for services to be provided to members enrolled in plans that do not include out-of-network benefits (including, but not limited to, Horizon HMO plans, Horizon EPO plans, OMNIASM Health Plans and Medicare Advantage HMO plans).

Q50.Why do members need to complete the Member Attestation for Use of an
Out-of-Network Provider form?
A50. Horizon BCBSNJ encourages the use of in-network doctors, facilities and other health care professionals to help members get the most out of their benefits and to help lower their out-of-pocket costs. If an out-of-network doctor, facility or other health care professional is chosen to participate in a procedure, it’s important that the member understands the financial impact of this decision.

When a member uses out-of-network benefits, in addition to being responsible for any out-of-network cost-sharing amounts (copayments, deductible and coinsurance amounts, as applicable), the member is also responsible for the difference between Horizon BCBSNJ’s allowance for eligible services and the out-of-network health care professionals’ total billed charges.

Q51.How will members be made aware thatthe Member Attestation for Use of an
Out-of-Network Provider form should be completed?
A51. When TurningPoint receives a request for the pre-approval (or prior authorization) of services to be rendered by an out-of-network doctor, facility and/or other health care professional, the member will receive a letter requesting that the Member Attestation for Use of an Out-of-Network Provider form be completed. A copy of the form will be included. As always, we encourage members to use participating doctors, facilities and health care professionals to help reduce their out-of-pocket costs.