PA/MND Process

Through the Surgical and Implantable Device Management Program, TurningPoint will conduct PA/MND review for orthopedic services and related devices to:

  • Determine medical necessity
  • Ensure appropriate conservative therapies are attempted prior to invasive procedures
  • Ensure the most appropriate surgery is performed
  • Ensure the right device is selected for the right patient
  • Ensure the procedure is performed in the right setting
  • Improve health care professional best practices

On October 22, 2018, TurningPoint will begin accepting PA/MND requests for services to be performed on or after November 1, 2018.

PHYSICIAN RESPONSIBILITIES

Physicians (both participating and nonparticipating) are required to obtain PA/MND from TurningPoint prior to performing services included as part of this program to be provided to Horizon BCBSNJ members enrolled in fully insured products (and to those Horizon BCBSNJ members enrolled in fully insured products that include BlueCard® benefits when services are to be provided within another Blue Cross and Blue Shield plan’s service area).

PA/MND requests may be submitted to TurningPoint:

  • Beginning October 22, 2018, you may log on to NaviNet® to submit a request.
     
  • If you do not have access to NaviNet, you can submit a request using TurningPoint’s web portal at https://www.myturningpoint-healthcare.com. To register for access to TurningPoint’s web portal, call TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., ET. You may also call TurningPoint at this phone number to submit PA/MND requests.

When contacting TurningPoint to obtain a PA/MND, please have the following information available:

  • The member’s name, date of birth and Horizon BCBSNJ ID number
     
  • The rendering, referring or ordering physician’s name, NPI/TIN, contact information (including fax number). Please also include the name and information of any co-surgeon or assistant surgeon, if any are anticipated to be necessary.
     
  • The rendering facility’s name, NPI/TIN, location address, contact information (including fax number)
     
  • CPT® codes and diagnosis codes
     
  • Place of service
     
  • All relevant clinical notes, imaging/X-ray reports and any anticipated implant, technology or hardware to be used
     
  • Out-of-Network Health Care Professionals to be used: At the time a PA/MND request is made, the referring/rendering physician is responsible to provide TurningPoint with information about the planned use of an out-of-network provider (co-surgeon, assistant surgeon, anesthesiologist, facility, etc.) in the surgical procedure.

TurningPoint will use this information to make determinations for PA/MND requests and to perform claim reviews.

FACILITY RESPONSIBILITIES

Rendering hospitals and ambulatory surgical centers are encouraged to confirm with the rendering physician or TurningPoint that an approved authorization or pre-service MND has been obtained.

Rendering facilities may confirm the status of a PA/MND by one of the following methods:

  • Beginning October 22, 2018, you may log on to NaviNet to confirm the status of a PA/MND request.
     
  • If you do not have access to NaviNet, you can confirm the status of a PA/MND request at https://www.myturningpoint-healthcare.com. To register for access to TurningPoint’s web portal, please call TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., ET.
     
  • You may also call TurningPoint at 1-833-436-4083 to confirm the status of a PA/MND.

 

CPT® is a registered trademark of the American Medical Association.

NaviNet® is a registered trademark of NaviNet, Inc.

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.