Horizon Blue Cross Blue Shield of New Jersey Surgical and Implantable Device Management Program

October 2018 ~

In December, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) will implement a new specialty utilization management program for certain orthopedic surgeries and will conduct prior authorization & medical necessity determination (PA/MND) reviews for certain orthopedic surgery services rendered in ambulatory surgical center, physician’s offices, and inpatient and outpatient settings.

Effective Monday, December 3, 2018, Horizon BCBSNJ will implement a new specialty utilization management program in collaboration with TurningPoint Healthcare Solutions, LLC (TurningPoint) for certain orthopedic surgeries, many of which may require the use of an implantable device. Through Horizon BCBSNJ’s Surgical and Implantable Device Management Program, TurningPoint will conduct Prior Authorization & Medical Necessity Determination (PA/MND) reviews for certain orthopedic surgery services that are requested by participating and nonparticipating physicians rendered in the following settings:

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

This program applies only to Horizon BCBSNJ members enrolled in fully insured plans/products and to Horizon BCBSNJ members enrolled in fully insured plans/products that include BlueCard® benefits for care received outside of Horizon BCBSNJ’s local service area.

Horizon BCBSNJ notes that TurningPoint will accept requests for PA/MNDs starting on Monday, November 19, 2018 for any in-scope orthopedic surgical procedure to be performed on or after Monday, December 3, 2018. Common procedures subject to PA/MND review under this program include:

Joint Reconstructive & Fusion Surgeries
(Including all associated revision surgeries)

  • Knee Arthroplasty
  • Hip Arthroplasty
  • Shoulder Arthroplasty
  • Elbow Arthroplasty
  • Ankle Arthroplasty
  • Wrist Arthroplasty
  • Hip Resurfacing
  • Shoulder Fusion
  • Elbow Fusion
  • Ankle Fusion
  • Wrist Fusion

Sports Medicine Surgeries

  • ACL Repair
  • Acromioplasty & Rotator Cuff Repair
  • Femoroacetabular Arthroscopy
  • Knee Arthroscopy
  • Hip Arthroscopy
  • Meniscal Repair (with or w/o Allograft)
  • Osteochondral Defect Repair

PA and Pre-Service MND Review

Through the Surgical and Implantable Device Management Program, TurningPoint will conduct PA/MND review for orthopedic services and any related device 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 provider best practices

Physicians must obtain PA for services rendered in the inpatient setting and for members whose benefits also require PA for services rendered in an outpatient setting and in the physician’s office.

For members whose benefits do not require PA for services rendered in an outpatient setting or in the physician’s office, physicians are strongly encouraged to obtain a pre-service MND from TurningPoint prior to the surgery to ensure that services will be considered medically necessary and that coverage for the procedure will be provided. Services deemed not medically necessary when claims are received or reviewed may not be eligible for coverage or payment by Horizon BCBSNJ. Rendering hospitals and ambulatory surgical centers are responsible for confirming that an approved PA or pre-service MND has been obtained.

Source(s): Horizon Blue Cross Blue Shield of New Jersey News & Legal Notices;

 

 

AdvantEdge