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TurningPoint Surgical and Implantable Device Management Program to Expand to Spine-Related Services

Effective February 1, 2022,¹ in collaboration with TurningPoint Healthcare Solutions LLC. (TurningPoint), our Surgical and Implantable Device Management Program will expand to include certain spine-related services, which will include non-surgical and surgical services that may use an implantable device (“spine-related services”).

Musculoskeletal Program for Spine SurgeryProgram by eviCore healthcare to end

As a result of the TurningPoint program expansion to include spine-related services, effective February 1, 2022, Horizon will sunset spine-related services as part of our Musculoskeletal Program for Spine Surgery, managed by eviCore healthcare (eviCore). Do not submit any requests to eviCore for review of spine-related services to be rendered on and after February 1, 2022. However, eviCore will continue to review pain management services as part of our Musculoskeletal Program.

Submitting PA/MND to TurningPoint

Beginning January 18, 2022, please submit requests to TurningPoint for Prior Authorization & Medical Necessity Determination (PA/MND) reviews of spine-related services to be performed on and after February 1, 2022. This impacts patients enrolled in:

  • Horizon commercial products, including certain Administrative Services Only (ASO) groups
  • Medicare Advantage (including Braven Health℠)

Services rendered in the observation setting or the Emergency Room (ER) do not require PA/MND. Services that are determined to be not medically necessary may not be eligible for coverage or payment. Horizon reserves the right to adjust claims based on TurningPoint’s recommendations.

More information about this program, including a list of impacted services/codes and other resources, is available at HorizonBlue.com/tpspine. If you have any questions, please contact your Hospital Network Specialist.

¹The expansion of the TurningPoint program to include management of spine-related services is subject to the approval of the NJ Department of Banking and Insurance. In the event regulatory approval is not obtained by February 1, 2022, the TurningPoint expansion and the sunsetting of eviCore’s management of spine-related services will be delayed. In that event, further communication will be issued.

TurningPoint Healthcare Solutions, LLCsupports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain surgical services that require the use of an implantable device for coverage. TurningPoint Healthcare Solutions, LLCand eviCore healthcare are independent from, and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association..

Published on: November 1, 2021, 13:25 p.m. ET
Last updated on: October 29, 2021, 03:58 a.m. ET