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:
- Submit a request online through eviCore.com
- Call 1-866-241-6603, between 7 a.m. and 7 p.m., Eastern Time
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.
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.
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.
Program Implementation Delayed: TurningPoint Surgical and Implantable Device Management Program for Spine Services
We are delaying the previously announced February 1, 2022 expansion of our Surgical and Implantable Device Management Program to include Spine Services for Horizon’s commercial and Medicare Advantage plans, including Braven Health℠.
The new effective date of this program expansion is April 1, 2022.
Please continue to work with eviCore healthcare for PA/MND requests/reviews for impacted spine-related services until further notice. Check our News & Legal Notices section for updates.
The expansion of the TurningPoint program to include management of spine-related services is subject to the approval of the New Jersey Department of Banking and Insurance. If regulatory approval is not obtained by April 1, 2022, the TurningPoint expansion and the sun setting of eviCore’s management of spine-related services will be delayed, and further communications will be issued.
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.
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.
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.