Effective June 6, 2022, in collaboration with TurningPoint, Horizon’s Surgical and Implantable Device Management Program will expand to include certain spine-related services which will include non-surgical and surgical services that may use an implantable device (“spine-related services”).
Musculoskeletal Program for Spine Surgery Program by evicore HealthCare to end
Effective June 6, 2022, Horizon will sunset spine-related services from our Musculoskeletal Program for Spine Surgery, managed by eviCore HealthCare. Do not submit any requests to eviCore for review of spine-related services rendered on and after June 6, 2022. eviCore will continue to review services for pain management under this program.
Submitting PA/MND to TurningPoint
Beginning May 23, 2022, please begin submitting requests to TurningPoint for Prior Authorization & Medical Necessity Determination (PA/MND) reviews of spine-related services to be performed on and after the program implementation date. This impacts patients enrolled in:
- Horizon commercial and level-funding plans/products
- Certain Administrative Services Only (ASO) employer groups
- Medicare Advantage (including Braven HealthSM) plans
We encourage you to seek a pre-service MND from TurningPoint to review spine-related services include those provided in inpatient, outpatient, Ambulatory Surgical Center or physician office settings. Services rendered in the observation setting or the Emergency Room (ER) do not require PA/MND.
Services that are determined to be not medically necessary may not be eligible for coverage or payment. Horizon reserves the right to adjust claims based on TurningPoint’s recommendations.
- Spinal Fusion Surgeries
- Disc Replacement
- Sacroiliac Joint Fusion
- Implantable Pain Pumps
- Spinal Cord Neurostimulator
- Spinal Decompression
Access the full list of Spine Procedure Codes Subject to PA/MND under this program.
TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain surgical services that require the use of an implantable device for coverage. TurningPoint Healthcare Solutions, LLC and eviCore HealthCare are independent from, and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association. The Braven Health name and symbols are a service mark of Braven Health.