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

As a reminder, beginning July 15, 2019, the Surgical and Implantable Device Management program for orthopedic services will also apply to members enrolled in Horizon BCBSNJ Medicare Advantage plans.

Through this specialty utilization management program, which Horizon BCBSNJ collaborates with TurningPoint Healthcare Solutions LLC (TurningPoint), 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 services provided to Horizon BCBSNJ members enrolled in fully insured plans/products and to those members in fully insured plans/products that include BlueCard® benefits for care received outside of Horizon BCBSNJ’s local service area²,³.

Beginning July 1, 2019, TurningPoint will begin accepting PA/MND requests for orthopedic surgery services to be rendered on and after July 15, 2019 to members enrolled in Horizon BCBSNJ Medicare Advantage plans.

View more about this program, including a full listing of the procedures and CPT® codes that are subject to PA/MND review under this program. You can also review information about the PA/MND review process and medical policy guidelines TurningPoint uses to conduct their reviews.

Questions?

Horizon BCBSNJ values your participation in our network and the care you provide to our members. If you have any questions, call 1-833-436-4083 Monday through Friday between 8 a.m. and 5 p.m., Eastern Time.

¹Services rendered in the observation setting and the Emergency Room (ER) are not reviewed by TurningPoint as part of this program. ²Horizon 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).

³To determine member eligibility and benefits, physicians can call the phone number on the back to the member’s ID card. For BlueCard benefit inquiries call 1-800-676-2583.

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: June 25, 2019, 05:37 AM ET
Last updated on: June 26, 2019, 01:11 AM ET