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Surgical and Implantable Device Management Program to be Implemented

Beginning December 3, 2018, Horizon Blue Cross Blue Shield of New Jersey will introduce a new specialty utilization management program, in collaboration with TurningPoint Healthcare Solutions, LLC (TurningPoint). The Surgical and Implantable Device Management Program will apply to certain orthopedic surgeries, many of which may require the use of an implantable device, and will help to ensure that you receive the right care at the right time.

Through Horizon BCBSNJ’s Surgical and Implantable Device Management Program, TurningPoint will conduct Prior Authorization & Medical Necessity Determination (PA/MND) reviews for certain orthopedic surgery services that are requested by doctors in the following places of care¹:

  • Inpatient
  • Outpatient
  • Ambulatory Surgical Center
  • Physician’s Office

This program applies only to Horizon BCBSNJ members enrolled in fully insured plans/products and to Horizon BCBSNJ members enrolled in fully insured plans/products that include BlueCard® benefits when they receive care outside of Horizon BCBSNJ’s local service area².

Some of the most common services that need to be approved through TurningPoint include:

Joint Reconstructive & Fusion Surgeries (Including all associated revision surgeries)
  • Knee Arthroplasty
  • Hip Arthroplasty
  • Shoulder Arthroplasty
  • Elbow Arthroplasty
  • Ankle Arthroplasty
  • Wrist Arthroplasty
  • Hip Resurfacing
  • Shoulder Fusion
  • Elbow Fusion
  • Ankle Fusion
  • Wrist Fusion

Sports Medicine Surgeries
  • ACL Repair
  • Acromioplasty & Rotator Cuff Repair
  • Femoroacetabular Arthroscopy
  • Knee Arthroscopy
  • Hip Arthroscopy
  • Meniscal Repair (with or w/o Allograft)
  • Osteochondral Defect Repair

Your doctor can request a PA/MND for necessary orthopedic surgery services by calling TurningPoint at 1-833-436-4083 Monday through Friday between 8 a.m. and 5 p.m., ET. They may also find more details at HorizonBlue.com/turningpoint.

You or your doctor may request copies of the medical policy criteria and guidelines that TurningPoint will conduct PA/MND reviews as part of this program by calling TurningPoint at 1-833-436-4083 Monday through Friday between 8 a.m. and 5 p.m., Eastern Time (ET).

As always, we encourage you to speak with your doctor about the orthopedic care that might be right for you. Horizon BCBSNJ remains committed to helping you access the care you need when you need it and reducing your out-of-pocket costs.

¹PA/MND is not required for services that are rendered in a hospital observation care setting or Emergency Room.

²Horizon BCBSNJ’s local service area includes the State of New Jersey, the contiguous counties in DE, NY and PA as well as Lehigh County, PA.

TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and review of certain orthopedic surgery services for coverage. TurningPoint Healthcare Solutions, LLC is independent from, and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.