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PA/MND Process

Through the Surgical and Implantable Device Management Program, TurningPoint will conduct PA/MND review for Orthopedic Services, Spine Services or Cardiac Services and related devices to:

  • Determine medical necessity
  • Ensure appropriate conservative therapies are attempted prior to invasive procedures
  • Ensure the most appropriate surgery is performed
  • Ensure the right device is selected for the right patient
  • Ensure the procedure is performed in the right setting
  • Improve health care professional best practices

PROVIDER RESPONSIBILITIES

Physicians (both participating and nonparticipating) are required to obtain PA/MND from TurningPoint for services to be provided to patients enrolled in plans/products that participate in this program. Rendering hospitals and ambulatory surgical centers are strongly encouraged to confirm with TurningPoint that an approved authorization or pre-service MND has been obtained for services to be provided to patients enrolled in plans/products that participate in this program.

Submitting a PA/MND Request

To submit a PA/MND request to TurningPoint:

  • Log on to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:

    • Mouse over Referrals & Authorization and select TurningPoint PA/MND Requests
    • Select Requests within the menu bar of TurningPoint’s home page, or click the Add Request shortcut.
       
  • If you do not have access to NaviNet, you can submit a request using TurningPoint’s web portal at https://www.myturningpoint-healthcare.com. 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.
  • You may also call TurningPoint at 1-833-436-4083 to submit PA/MND requests.

When contacting TurningPoint to obtain a PA/MND, please have the following information available:

  • The member’s name, date of birth and Horizon BCBSNJ ID number.
  • The rendering, referring or ordering physician’s name, NPI/TIN, contact information (including fax number). Please also include the name and information of any co-surgeon or assistant surgeon, if any are anticipated to be necessary.
  • The rendering facility’s name, NPI/TIN, location address, contact information (including fax number)
  • CPT® codes and diagnosis codes
  • Place of service
  • Anticipated date of service
  • All relevant clinical information, including:
    • History of present illness
    • Attempted conservative therapies (including physical therapy notes)
    • Radiographic findings
    • Documented surgical plan
    • Device product type and device manufacturer information (if applicable)
  • Out-of-Network Health Care Professionals to be used: At the time a PA/MND request is made, the referring/rendering physician is responsible to provide TurningPoint with information about the planned use of an out-of-network provider (co-surgeon, assistant surgeon, anesthesiologist, facility, etc.) in the surgical procedure.

TurningPoint will use this information to make determinations for PA/MND requests and to perform claim reviews.

Validating PA/MND Status

Rendering hospitals and ambulatory surgical centers are encouraged to confirm that an approved authorization or pre-service MND has been obtained.

  • Rendering facilities may confirm the status of a PA/MND by calling TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., ET

TurningPoint is able to provide approval/denial notifications directly to rendering facilities.

  • Facilities are strongly encouraged to call TurningPoint at 1-833-436-4083 to provide the contact information for the appropriate persons/departments to receive future TurningPoint authorization and pre-service MND determination notifications.

 

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, spine 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.