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.