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Medical Policy Criteria and Guidelines

TurningPoint manages and maintains the medical policy criteria and guidelines used to conduct PA/MND reviews as part of this program. The medical policy criteria and guidelines apply only to those Horizon BCBSNJ members included within the scope of this program when rendered on or after the effective date.

  • You may review the medical policy criteria and guidelines online. To access this information, sign in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:
    • Mouse over Referrals & Authorization and select TurningPoint PA/MND Requests
    • Select Help from the menu bar of TurningPoint’s home page
    • Select Medical Policies and Clinical Guidelines within the Helpful Articles section

If you do not have access to NaviNet, you may access the medical policy criteria and guidelines used to conduct PA/MND reviews as part of this program through TurningPoint’s web portal. To register for access to TurningPoint’s web portal, call TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., ET to register to obtain access credentials.

  • You can also obtain copies of the medical policy criteria and guidelines by calling TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., Eastern Time (ET).

Medical Policy Criteria/Guidelines applicable to Federal Employee Program® Members

  • For cardiac and orthopedic services provided to members enrolled in Federal Employee Program® (FEP®) plans, the criteria and guidelines included in our medical policies will apply if no pertinent guidelines exist within the FEP Medical Policy Manual.

  • For spine services provided August 14, 2023 and after to FEP members, the criteria and guidelines included in our medical policies will apply if no pertinent guidelines exist within theFEP Medical Policy Manual.

The content of TurningPoint policies may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). In the processing of claims for services provided to our MA members, we follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs. For those services where no LCD or NCD exists, claims for MA members will be processed based on TurningPoint policy criteria and guidelines.

CPT® is a registered trademark of the American Medical Association.
NaviNet® is a registered trademark of NaviNet, Inc.
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 Blue Shield Association.