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Musculoskeletal Program

Horizon Blue Cross Blue Shield of New Jersey is committed to providing your patients, our members, with access to high-quality health care services that are consistent with nationally recognized clinical criteria and guidelines.

As part of that commitment, Horizon BCBSNJ collaborates with eviCore healthcare (eviCore) to administer our Musculoskeletal Program. eviCore conducts Prior Authorization and/or Medical Necessity Determination (PA/MND) reviews of certain musculoskeletal pain management and spine surgery services.

To obtain PA/MND from eviCore for musculoskeletal pain management or spine surgery services, please:

Claim processing will be delayed and services may be denied if a PA/MND is not obtained prior to services being rendered.

Participating providers, based on their Agreements/Contracts with us, may not seek payment from members for denied claims/services because a PA/MND was not obtained prior to the performance of services or because medical documentation was requested from the referring or rendering provider.

Please note that eligibility and participation may vary based on line of business therefore, all providers should check eligibility and benefits prior to performing any services related to this program. In addition, actual benefit determinations cannot be made until a claim is received and is subject to the provisions of the patient’s present contract including any applicable deductible, coinsurance and/or coordination of benefits. Payment is dependent on the patient being an eligible Horizon BCBSNJ member at the time the services are rendered. Authorizations will be affected should the claim submitted differ from the information provided at the time of a request.

If you have questions, please call eviCore at 1-866-241-6603.

eviCore healthcare supports Horizon BCBSNJ in the administration and utilization management review of certain musculoskeletal pain management and spine surgery services as part of our Musculoskeletal Program. eviCore healthcare is independent from, and not affiliated with Horizon BCBSNJ or the Blue Cross Blue Shield Association.

eviCore healthcare is a registered trademark of eviCore healthcare

Horizon Blue Cross Blue Shield of New Jersey collaborates with eviCore healthcare (eviCore) to administer a Prior Authorization and/or Medical Necessity Determination (PA/MND) review program for certain musculoskeletal pain management services.

Pain Management Code Changes
Effective June 6, 2022, as a result of the Surgical and Implantable Device Management Program expansion to include spine-related services, administered by TurningPoint, the following codes will no longer be reviewed by eviCore as part of this program: 63650, 63655, 63663, 63664, 63685, 62350, 62351, 62360, 62361 and 62362.

  • Submit PA/MND requests to TurningPoint
    Please submit PA/MND requests to TurningPoint for procedure codes 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63663, 63664, 63685 for services provided June 6, 2022 and after for patients participating in our Surgical and Implantable Device Management Program for Spine Services.

  • Submit PA/MND requests to Horizon for SHBP/SEHBP patients
    Please submit PA/MND requests to Horizon via our online Utilization Management Request Tool for codes 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63663, 63664, 63685 for services provided after June 5, 2022 to patients enrolled in State Health Benefits Program (SHBP)/School Employees' Health Benefits Program (SEHBP) plans.

PA/MND for Anesthesia Services
Anesthesia services performed in conjunction with musculoskeletal pain management procedures require separate prior authorization and/or Medical Necessity Determination. Claims submitted for anesthesia services related to a pain management procedure will not be paid if there a valid authorization is not on file.

Policies
The Horizon BCBSNJ Medical Policies on pain management were developed using recognized evidence-based guidelines and incorporate criteria derived from published materials that are supported by nationally-recognized agencies such as the American Society of Interventional Pain Physicians, the American Pain Society, the American Academy of Pain Management and the National Institutes of Health.

Medical Policy Manual Policy
Access the Horizon BCBSNJ Medical Policy Manual to view clinical criteria and guidelines related to musculoskeletal pain management services.

Resources
Review Pain Management Services Frequently Asked Questions.

Musculoskeletal Program for Spine Surgery to be sunset
Effective June 6, 2022, as a result of the Surgical and Implantable Device Management Program expansion to include spine-related services, administered by TurningPoint, Horizon will sunset the spine-related services part of our Musculoskeletal Program, managed by eviCore healthcare.

  • eviCore will not perform PA/MND reviews of spine-related services that are to be rendered on or after June 6, 2022.
  • eviCore will continue to perform PA/MND reviews of Pain Management services as part of the Musculoskeletal Program.

Musculoskeletal Program for Spine Surgery Services

Horizon Blue Cross Blue Shield of New Jersey collaborates with eviCore healthcare (eviCore) to conduct Prior Authorization and Medical Necessity Determination (PA/MND) reviews for certain Spine Surgery services for members enrolled in Horizon BCBSNJ fully insured products as well as ASO accounts that have elected the Musculoskeletal Program.

No reimbursement will be made for Spine Surgery services provided by a nonparticipating professional/facility unless PA/MND is obtained.

If an out-of-network co-surgeon will be used in the Spine Surgery, the referring/rendering health care professional is responsible for:

  • Notifying eviCore, AND
  • Informing the patient that he/she will be responsible for the higher out-of-pocket costs associated with using a nonparticipating co-surgeon.

Policies
Horizon BCBSNJ has adopted the eviCore guidelines for Spine Surgery services for use with members who are enrolled in plans that participate in the Musculoskeletal Program administered by eviCore.

Visit www.eviCore.com/HorizonSpineSurgery to access the Spine Surgery guidelines that apply to members enrolled in plans that have elected to participate in the Musculoskeletal Program administered by eviCore.

The eviCore guidelines were developed using recognized evidence-based guidelines and incorporate criteria derived from published materials that are supported by nationally-recognized agencies such as the American Society of Interventional Pain Physicians, the American Pain Society, the American Academy of Pain Management and the National Institutes of Health.

Please note that the Spine Surgery guidelines maintained on eviCore’s website pertain only to members who are enrolled in Horizon BCBSNJ plans that participate in the Musculoskeletal Program for Spine Surgery administered by eviCore.

Resources

Musculoskeletal Program for Spine Surgery Services Quick Reference Guide

Horizon BCBSNJ announcement of the Musculoskeletal Program for Spine Surgery Services

eviCore HealthCare and TurningPoint Healthcare Solutions, LLC are independent from, and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association. The Braven Health name and symbols are a service mark of Braven Health.