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Orthopedic Services

Horizon BCBSNJ collaborates with TurningPoint to administer PA/MND review for certain orthopedic services, many of which require the use of an implantable device.

Review the procedures subject to PA/MND as part of our Surgical and Implantable Device Management Program for Orthopedic Services.

Members included in this program for orthopedic services

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

  • Horizon BCBSNJ fully insured plans/products including those members enrolled in fully insured plans that include BlueCard® benefits for care received outside of our local service area (i.e., all NJ counties, the contiguous counties in DE, NY and PA, as well as Lehigh County, PA).
  • Horizon BCBSNJ Medicare Advantage (MA) plans.
  • State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans/products.
  • As of June 28, 2021 Federal Employee Plans® (FEP®) Plans will also be included

You can determine member eligibility and benefits by calling the phone number on the back to the member’s ID card. For BlueCard benefit inquiries call 1-800-676-2583.

TurningPoint will NOT conduct PA/MND reviews of services to be provided to members enrolled in self-insured Administrative Services Only (ASO) plans as part of this program.

TurningPoint Safety and Quality Award Program

Beginning April 1, 2021, orthopedic specialists will be offered the opportunity to participate in the TurningPoint Safety and Quality Award Program, in collaboration with Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). This reward-based program will provide an incentive when your patients experience fewer complications, infections, hospital readmissions and Emergency Room visits following their surgical procedures, as well as reduced out-of-pocket costs associated with their surgery.

Addendums must have been received by March 15, 2021 however, there are opportunities to enroll in the program on a quarterly basis..

How it works

You must opt-in to the Safety and Quality Award Program to receive a quality award bonus payment. Award payments are calculated based on the performance of the surgeons within your orthopedic practice/group, and the following criteria must be met for each surgical procedure:

  • Quality & Safety
  • Infection & Risk Management
  • Site of Service Optimization
  • Procedure Documentation Standards

Incentive levels are categorized by type of service and based on your practice/group’s ability to demonstrate consistent use of the program’s best practice standards.

Q. Will any additional work be required of me or my office staff should I decide to participate in this program?

A. No, there is no additional work required from the provider’s office. TurningPoint owns the administrative responsibility to obtain post-operative notes from facilities. TurningPoint will work with specific provider offices to obtain facility contacts initially, but TurningPoint will manage the collection of clinical information, generate comprehensive reporting and set up follow-up meetings with the provider’s office to review the reporting data and program performance details. TurningPoint has dedicated staff to provide training and ongoing support.

To arrange training, please email TurningPoint’s Provider Relations at providersupport@turningpoint-healthcare.com or call 1-866-422-0800.

Q. Is there any downside to participating in this program?

A. There is no downside or risk involved with the Quality Award Program. There is no penalty for not meeting the award standards. During the reporting presentation with your office, you will be able to see exactly where the award could’ve been earned and why the metric was not met.

Resources

Surgical and Implantable Device Management Program for Orthopedic Services Q & A
Safety and Quality Award Program Q&A
Surgical and Implantable Device Management Program Provider Training Manual
Surgical and Implantable Device Management Program for Orthopedic Services Procedure Code Listing
Orthopedic Services Medical 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 and Blue Shield Association.