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Surgical and Implantable Device Program to Include Cardiac Services

Effective July 15, 2019, Horizon BCBSNJ will expand our Surgical and Implantable Device Management Program, administered by TurningPoint Healthcare Solutions, LLC (TurningPoint), to include Prior Authorization & Medical Necessity Determination (PA/MND) reviews for certain cardiac services, many of which may require the use of an implantable device.

TurningPoint will conduct PA/MND reviews of certain cardiac services to:

  • Determine medical necessity of the services to be provided
  • Ensure appropriate conservative therapies are attempted prior to invasive procedures
  • Help to ensure that the most appropriate surgery is performed in the most appropriate setting using the most appropriate device(s)
  • Help to improve provider best practices

TurningPoint will accept requests for PA/MND starting on July 1, 2019, for any in-scope cardiac procedures to be performed on or after July 15, 2019.

Some of the most common cardiac surgical procedures subject to PA/MND review under this program include:

Implantable Cardioverter Defibrillators
Pacemaker (Single Chamber)
Pacemaker (Dual Chamber)
Pacemaker (Leadless)
Stent (Angioplasty & Endovascular)
Stent (Drug Eluting)

Places of service included in this program

TurningPoint will conduct PA/MND reviews for services rendered in the following settings:

  • Inpatient
  • Outpatient
  • Ambulatory Surgical Center
  • Office setting

TurningPoint will not conduct PA/MND reviews of services rendered in the Emergency Room or an observation setting.

Members included in this program

TurningPoint will conduct PA/MND reviews of services to be provided to members enrolled in Horizon BCBSNJ fully insured plans/products (including those fully insured plans/products plans that include BlueCard® benefits for care received outside of our local service area).¹ ²

TurningPoint will not conduct PA/MND reviews of services to be provided to members enrolled in self-insured Administrative Services Only (ASO) plans as part of this program.³

Submitting a PA/MND request to TurningPoint

There are three ways you can request a PA/MND for a cardiac service:

  • Log on to NaviNet®, select Horizon BCBSNJ from the My Health Plans menu, and:
    • Mouse over Referrals & Authorization and select TurningPoint PA/MND Requests
    • Select Requests within the TurningPoint menu bar or click the Add Request shortcut
  • If you do not have access to NaviNet, you can submit a request via TurningPoint’s web portal at 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., Eastern Time.
  • Call TurningPoint at 1-833-436-4083 during the hours noted above.

Review the information TurningPoint requires for a PA/MND request.

Provider responsibilities

Physicians
Physicians are responsible for requesting PA/MND review from TurningPoint

Although some member benefits do not require prior authorization for services rendered in an outpatient setting or a physician’s office, physicians are strongly encouraged to obtain a pre-service MND from TurningPoint prior to providing cardiac services included in this program to ensure that services will be considered medically necessary.

Hospitals and Ambulatory Surgery Centers

Rendering hospitals and ambulatory surgical centers are encouraged to call TurningPoint at 1-833-436-4083 to confirm that a PA/MND has been obtained.

TurningPoint will provide authorization and pre-service PA/MND determination notifications to facilities if they are made aware of the appropriate persons/departments to receive such notification. Please call TurningPoint at 1-833-436-4083 to provide contact information to receive PA/MND determination notifications.

Cardiac services submitted on professional and facility claims that are reviewed by TurningPoint on a post-service basis and deemed not medically necessary will not be eligible for coverage or payment by Horizon BCBSNJ. Claims for impacted services will also be processed and reimbursed in a manner consistent with TurningPoint’s guidelines in regard to frequency rules and service maximums.

Medical policy criteria and guidelines
TurningPoint manages and maintains the medical policy criteria and guidelines used to conduct PA/MND reviews as part of this program expansion.

Program details and information
Information about this program including the following program resources are available.

Questions?
If you have any questions, call TurningPoint at 1-833-436-4083.

¹Horizon 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).

²You can determine member eligibility and benefits by calling the phone number on the back to the member’s ID card. For BlueCard benefit inquiries call 1-800-676-2583.

³The back of a self-insured ASO member ID card will state, “Horizon BCBSNJ provides administrative services only and does not assume any financial risk for claims.” A fully insured member’s ID card will not have that message. Please always verify member benefits, as it may be possible that the most current ID card is not presented at the time of service.

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 requiring implantable devices 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: April 15, 2019, 04:59 a.m. ET
Last updated on: April 15, 2019, 09:47 a.m. ET