Skip to main content
COVID-19
Stay informed. Get the latest information on COVID-19.

Using Out-of-Network Providers in Surgical Services

In compliance with the guidelines of our Out-of-Network Referral Policy, when a PA/MND request is made as part of the Surgical and Implantable Device Management Program, TurningPoint will obtain information about the planned use of any out-of-network physician, other healthcare professional, ancillary service provider, hospital, ambulatory surgery center or other facility (e.g., co-surgeon, assistant surgeon, anesthesiologist, facility, etc.) in a surgical procedure.

TurningPoint uses this information about the planned use of any out-of-network providers in a surgical procedure to help ensure:

  • That an out-of-network provider is NOT scheduled to participate in any surgical services provided to patients enrolled in Horizon BCBSNJ plans that DO NOT include out-of-network benefits.

  • That a patient enrolled in a Horizon BCBSNJ plan that includes out-of-network benefits:
    • Is aware of the planned use of an out-of-network physician, other healthcare professional, ancillary service provider, hospital, ambulatory surgery center or other facility in his/her upcoming surgical procedure.

    • Has been offered the opportunity to use an in-network physician, other healthcare professional, ancillary service provider, hospital, ambulatory surgery center or other facility in his/her planned surgical procedure, but has declined this offer and is knowingly, voluntarily, and specifically selecting to use an out-of-network physician, other healthcare professional, ancillary service provider, hospital, ambulatory surgery center or other facility in his/her planned surgical procedure.

    • Understands he/she may have higher out-of-pocket costs using an out-of-network physician, other healthcare professional, ancillary service provider, hospital, ambulatory surgery center or other facility in his/her planned surgical procedure.

TurningPoint may reach out to patients enrolled in Horizon BCBSNJ plans that include out-of-network benefits during the PA/MND process to ensure that the patient is aware of and understands that an out-of-network physician, other healthcare professional, ancillary service provider, hospital, ambulatory surgery center or other facility has been scheduled to participate in his/her upcoming surgical procedure.

TurningPoint will use our Member Attestation for Use of Out-of-Network Provider(s) form to document the patient’s decision in regard to using an out-of-network physician, other healthcare professional, ancillary service providers, hospital, ambulatory surgery center or other facility in his/her upcoming surgical procedure.

Rendering physicians may be required to sign this form to attest that they are acting in compliance with the guidelines of our Out-of-Network Referral Policy.

As always, members are encouraged to use in-network physicians and facilities to reduce their out-of-pocket costs. If you have questions, please call TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., ET.

Horizon BCBSNJ Out-of-Network Referral Policy

All participating physicians and other health care professionals are required to comply with, and adhere to, the guidelines of our Out-of-Network Referral Policy. This policy was implemented to help ensure that members are aware when an out-of-network physician, facility or other health care provider will be involved in his/her care and that the member fully understands the increased out-of-pocket expense they will incur.

Participating physicians who are planning to use an out-of-network co-surgeon, assistant at surgery, anesthesiologist, hospital, or surgery center in an orthopedic surgical service for a patient enrolled in a plan that includes out-of-network benefits are expected to fully comply with the guidelines of our Out-of-Network Referral Policy.

Participating physicians who fail to comply with our policies may be subject to loss or restriction of network participation and/or termination.

To access our Out-of-Network Referral Policy, registered NaviNet users should log on to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:

  • Select Provider Reference Materials.
  • Mouse over Policies & Procedures.
  • Select Policies, then Administrative Policies.
  • Select Out-of-Network Referral Policy.

FEP members and OON services

Federal Employee Plan® (FEP®) members are excluded from the above-noted TurningPoint PA/MND processes in regard to the use of out-of-network providers as well as the guidelines of our Out-of-Network Referral Policy.

FEP members will not be included in TurningPoint PA/MND processes that involve outreach to patients to ensure that the patient is aware of and understands that an out-of-network provider has been scheduled to participate in an upcoming surgical procedure, nor will FEP members be asked to complete our Member Attestation for Use of Out-of-Network Provider(s) form.

The FEP Standard Option plan includes OON benefits.

  • To help your patients maximize their benefits and minimize their out-of-pocket expenses, we encourage you to use participating physicians, other healthcare professionals, ancillary service providers, hospitals, ambulatory surgery centers or other facilities in planned surgical procedures for patients enrolled in the FEP Standard Option plan.

  • Claims for services provided by a nonparticipating providers to members enrolled in FEP Standard Option will be processed per their out-of-network benefits.

FEP Basic Option and Blue Focus plans DO NOT include out-of-network benefits.

  • Participating providers must use participating physicians, other healthcare professionals, ancillary service providers, hospitals, ambulatory surgery centers or other facilities in planned surgical procedures for patients enrolled in FEP Basic Option and Blue Focus plans.

  • Claims for nonparticipating provider services rendered to members enrolled in FEP Basic Option and Blue Focus plans will be denied.