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Transition from eviCore to TurningPoint: PA/MND Reviews of Spine Surgery Services

Group Update For Self-Insured Plans.

After collaborating with the New Jersey Department of Banking and Insurance (DOBI) to secure approval, Horizon will transition the Prior Authorization and Medical Necessity Determination (PA/MND) reviews of spine-related services from eviCore healthcare (eviCore) to TurningPoint Healthcare Solutions (TurningPoint). With this change, we anticipate that our customers will have access to comprehensive review services, while getting enhanced care management through TurningPoint.

Health care professionals can submit PA/MND review requests for spine-related services that will be provided on and after June 6, 2022 to TurningPoint beginning May 23, 2022.

Who Is Affected by This Change

The change will affect your group health plan as your group health plan has opted into our Musculoskeletal Program for Spine Surgery.

Quality Care for Your Covered Employees

Horizon remains committed to providing our members with access to high-quality health care services that are consistent with nationally recognized clinical criteria and guidelines. TurningPoint’s decisions will help make sure treatment options for your covered employees are appropriate — medically and financially. TurningPoint will support your covered employees, and their doctors and other health care professionals to achieve:

  • Better results after surgery
  • Faster recovery times
  • Lower risk of infection and other complications
  • High-quality care before and after surgery
  • Lower risk of additional surgery

What’s Not Changing

  • The per employee per month costs for TurningPoint’s spine-related services will be the same as eviCore’s spine-related services.
  • Services provided in the observation setting or the Emergency Room don’t require PA/MND review.
  • Services that are not medically necessary are not eligible for coverage or payment. Horizon reserves the right to adjust claims based on TurningPoint’s recommendations.
  • eviCore will continue to review PA/MND review requests for pain management services, if your group health plan has opted in to that program.
Published on: May 5, 2022, 02:14 a.m. ET
Last updated on: May 17, 2022, 00:57 a.m. ET