About the Surgical and Implantable Device Management Program

Horizon Blue Cross Blue Shield of New Jersey collaborates with TurningPoint Healthcare Solutions, LLC (TurningPoint) to administer our Surgical and Implantable Device Management Program.

As part of this program, TurningPoint conducts Prior Authorization & Medical Necessity Determination (PA/MND) reviews of certain Orthopedic services and Cardiac Services (many of which include implantable devices), and other related services, requested by participating and nonparticipating physicians when rendered in the following settings:

• Inpatient
• Outpatient
• Ambulatory Surgical Center
• Physician’s Office

Services rendered in the observation setting or the Emergency Room (ER) do not require PA/MND.

TurningPoint will conduct PA/MND reviews of certain orthopedic and 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

Obtaining an approved PA/MND from TurningPoint will ensure that the services in question will be considered medically necessary.

Physicians are strongly encouraged to obtain a pre-service MND from TurningPoint for services to be provided to patients whose benefits do not require PA of services rendered in an outpatient setting or in a physician’s office.

As part of our Surgical and Implantable Device Management Program, TurningPoint will review professional and facility claims submitted. Services that TurningPoint deems not medically necessary as part of this review may not be eligible for coverage or payment by Horizon BCBSNJ. Horizon BCBSNJ reserves the right to adjust claims based on TurningPoint’s recommendations.

Review detailed program information pertaining to Orthopedic Services or Cardiac Services

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TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain orthopedic and cardiac services 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.