Spine Services
Effective April 1, 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 April 1, 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 to be rendered on and after April 1, 2022. eviCore will continue to review services for pain management under this program.
Submitting PA/MND to TurningPoint
Beginning March 18, 2022, you can submit requests to TurningPoint for Prior Authorization & Medical Necessity Determination (PA/MND) reviews of spine-related services to be performed on and after April 1, 2022. This impacts patients enrolled in:
- Horizon commercial 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.
Covered Services
- Spinal Fusion Surgeries
- Cervical
- Lumbar
- Thoracic
- Sacral
- Scoliosis
- Disc Replacement
- Laminectomy/Discectomy
- Kyphoplasty/Veterbroplasty
- 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.
The expansion of the TurningPoint program to include management of spine-related services is subject to the approval of the NJ Department of Banking and Insurance. Horizon hopes to obtain approval prior to the planned April 1, 2022, program effective date. In the event regulatory approval is not obtained by then, the TurningPoint expansion and the sun setting of eviCore’s management of spine-related services will be delayed. In that event, further communication will be issued.
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.