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Additional Member Plans to be Included as part of our Surgical and Implantable Device Management Program for Orthopedic Surgeries

Beginning on July 15, 2019, the Surgical and Implantable Device Management program for orthopedic surgery services will expand to also apply to members enrolled in Horizon BCBSNJ Medicare Advantage plans.

Through this program, TurningPoint Healthcare Solutions LLC (TurningPoint) conducts Prior Authorization & Medical Necessity Determination (PA/MND) reviews for certain orthopedic surgery services that are requested by participating and nonparticipating physicians when rendered in the following settings¹:

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

Initially, this program only applied to Horizon BCBSNJ members enrolled in fully insured plans/products and in fully insured plans/products that include BlueCard® benefits for care received outside of Horizon BCBSNJ’s local service area. To determine member eligibility and benefits, your or your can call the phone number on the back to your member ID card.² ³

Some of the most common services reviewed as part of this program 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., Eastern Time. 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 uses to conduct PA/MND reviews as part of this program by calling TurningPoint at 1-833-436-4083.

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.

 

¹Services rendered in the observation setting and the Emergency Room (ER) are not reviewed by TurningPoint as part of this program.
² Horizon BCBSNJ members enrolled in plans that include BlueCard benefits who receive care outside of Horizon BCBSNJ’s service area which includes the State of New Jersey, contiguous counties in DE, NY and PA (as well as Lehigh County, PA).
³ For BlueCard benefit inquiries call 1-800-676-2583

 

 

CPT® is a registered trademark of the American Medical Association.
NaviNet® is a registered trademark of NaviNet, Inc.
TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain surgical services that require an implantable device 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.

Published on: July 15, 2019, 03:25 AM ET
Last updated on: July 8, 2019, 06:36 AM ET