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Musculoskeletal Program for Pain Management Services

Horizon BCBSNJ 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, we collaborate with eviCore healthcare (eviCore) to administer a Prior Authorization and/or Medical Necessity Determination (PA/MND) review program for certain musculoskeletal pain management services.


Recent Pain Management Code Changes

As a result of the Surgical and Implantable Device Management Program expansion to include spine-related services, eviCore no longer performs PA/MND reviews of 63650, 63655, 63663, 63664, 63685, 62350, 62351, 62360, 62361 or 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 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 patients enrolled in State Health Benefits Program (SHBP)/School Employees' Health Benefits Program (SEHBP) plans.

Members included in this program

eviCore will conduct PA/MND reviews of services included in the scope of this program that are to be provided to members enrolled in the following plans/programs:

  • Horizon fully insured or level-funded plans/products including those members enrolled in plans that include BlueCard® benefits for care received outside of our local service area
  • Horizon Medicare Advantage and Braven Health Medicare Advantage plans
  • State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) employer group plans

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.

Obtaining PA/MND

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

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.

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.

First Level Utilization Management (UM) Appeals

  • Fax first level UM appeals for Horizon Medicare Advantage and Braven Health Medicare Advantage members to 1-609-583-3028 or mail to:

    Braven Health Medical Appeals PO Box 10195 Newark, NJ 07101
    Horizon Medicare Advantage Medical Appeals PO Box 10195 Newark, NJ 07101
  • Fax first level UM appeals for Horizon fully insured commercial and ASO members to 1-866-699-8128 or mail to:

    eviCore healthcare Attn: Clinical Appeals Mail Stop 600 400 Buckwalter Place Blvd Bluffton, SC 29910

Medical Policies

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

Resources

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 services as part of our Musculoskeletal Program for Pain Management Services.

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