About the Surgical and Implantable Device Management Program

Beginning November 1, 2018, Horizon Blue Cross Blue Shield of New Jersey will collaborate with TurningPoint Healthcare Solutions, LLC (TurningPoint) to administer our Surgical and Implantable Device Management Program.

As part of this program, TurningPoint will conduct Prior Authorization & Medical Necessity Determination (PA/MND) reviews of certain orthopedic surgical services (many of which include implantable devices), and other related services, for members enrolled in Horizon BCBSNJ fully insured plans/products and that are requested by participating and nonparticipating physicians rendered in the following settings:

  • Inpatient
  • Outpatient
  • Ambulatory Surgical Center
  • Physician’s Office

Services rendered in the observation setting or the Emergency Room (ER) do not require PA/MND.

TurningPoint will also perform PA/MND of services to be provided to those Horizon BCBSNJ members enrolled in fully insured plans/products that include BlueCard® benefits when services are to be provided outside of Horizon BCBSNJ’s local service area. (Horizon BCBSNJ’s local service area includes the State of New Jersey, contiguous counties in DE, NY and PA as well as Lehigh County, PA.)

Obtaining an approved PA/MND from TurningPoint will ensure that the services in question will be considered medically necessary.

TurningPoint will accept requests for PA/MNDs starting on October 22, 2018 for any in-scope orthopedic surgical procedures to be performed on or after November 1, 2018.

Physicians are strongly encouraged to obtain a pre-service MND from TurningPoint for services to be provided to patients whose benefits do not require PA of services rendered in an outpatient setting or in a physician’s office.

As part of our Surgical and Implantable Device Management Program, TurningPoint will review professional and facility claims submitted for services rendered on or after November 1, 2018. Services that TurningPoint deems not medically necessary as part of this review may not be eligible for coverage or payment by Horizon BCBSNJ. Horizon BCBSNJ reserves the right to adjust claims based on TurningPoint’s recommendations.

Review the full listing of procedures subject to PA/MND as part of our Surgical and Implantable Device Management Program.
 

Resources

Surgical and Implantable Device Management Program Q & A

Horizon BCBSNJ announcement of the Surgical and Implantable Device Management Program

 

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TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain orthopedic surgical 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 and Blue Shield Association.