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Surgical and Implantable Device Management Program to be Implemented

Beginning November 1, 2018, Horizon Blue Cross Blue Shield of New Jersey will implement a new specialty utilization management program in collaboration with TurningPoint Healthcare Solutions, LLC (TurningPoint) for certain orthopedic surgeries, many of which may require the use of an implantable device. 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 participating and nonparticipating physicians rendered in the following settings1:

  • 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 for care received outside of Horizon BCBSNJ’s local service area2.

TurningPoint will accept requests for PA/MNDs starting on October 22, 2018 for any in-scope orthopedic surgical procedure to be performed on or after November 1, 2018.

Some of the most common procedures subject to PA/MND review under 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

View more information about this new program, including a full listing of the procedures and CPT® codes that are subject to PA/MND review under this program.

PA and Pre-Service MND Review

Through the Surgical and Implantable Device Management Program, TurningPoint will conduct PA/MND review for orthopedic services and any related device to:

  • Determine medical necessity
  • Ensure appropriate conservative therapies are attempted prior to invasive procedures
  • Ensure the most appropriate surgery is performed
  • Ensure the right device is selected for the right patient
  • Ensure the procedure is performed in the right setting
  • Improve provider best practices

Physicians must obtain PA for services rendered in the inpatient setting and for members whose benefits also require PA for services rendered in an outpatient setting and in the physician’s office.

For members whose benefits do not require PA for services rendered in an outpatient setting or in the physician’s office, physicians are strongly encouraged to obtain a pre-service MND from TurningPoint prior to the surgery to ensure that services will be considered medically necessary and that coverage for the procedure will be provided. Services deemed not medically necessary when claims are received or reviewed may not be eligible for coverage or payment by Horizon BCBSNJ.

Rendering hospitals and ambulatory surgical centers are responsible for confirming that an approved PA or pre-service MND has been obtained.

  • Beginning October 22, 2018, 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 using TurningPoint’s web portal at https://www.myturningpoint-healthcare.com. To register for access to TurningPoint’s web portal, call TurningPoint at 1-833-436-4083, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time (ET).
  • You may also call TurningPoint at 1-833-436-4083 to confirm the status of a PA/MND.

If an out-of-network co-surgeon or assistant surgeon will be participating in the surgical procedure, it is the referring/rendering physician’s responsibility to notify TurningPoint at the time of the PA/MND request.

How to Obtain PA/MND for Orthopedic Services

  • Beginning October 22, 2018, a physician may log on to NaviNet® to submit a request.
  • Practices that do not have access to NaviNet 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, Monday through Friday between 8 a.m. and 5 p.m., ET.
  • You may also call TurningPoint at 1-833-436-4083 to submit PA/MND requests.

TurningPoint must be provided with:

  • The member’s:

    − Horizon BCBSNJ ID number

    − First and last names

    − Date of birth

  • The rendering, referring or ordering physician’s:

    − First and last names

    − National Provider Identifier (NPI)

    − Tax Identification Number (TIN)

    − Fax number

    − The above information should also be provided for any co-surgeon or assistant surgeon deemed necessary to perform the requested procedure(s)

  • The rendering facility’s:

    − Name

    − NPI

    − TIN

    − Street address

    − Fax number

  • CPT codes and diagnosis codes
  • Place of service
  • All relevant clinical notes, imaging/X-ray reports and any anticipated implant, technology or hardware to be used.

TurningPoint will use this information to make determinations for PA/MND requests and to perform claim reviews.

Medical Policy Criteria and Guidelines

Physicians and facilities can call TurningPoint at 1-833-436-4083 to request the medical policy criteria and guidelines TurningPoint will use to conduct PA/MND reviews. The medical policy criteria and guidelines will be effective November 1, 2018. TurningPoint’s medical policy criteria and guidelines pertain only to Horizon BCBSNJ fully insured members.

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., ET.

¹ Services rendered in the observation setting and the Emergency Room (ER) are excluded.
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 To 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.

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 orthopedic surgical 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.

Published on: July 30, 2018, 07:27 AM ET
Last updated on: August 1, 2018, 15:20 PM ET