Surgical and Implantable Device Management Program
Horizon NJ Health is collaborating with TurningPoint Healthcare Solutions, LLC (TurningPoint) effective July 1, 2022, to administer our Surgical and Implantable Device Management Program for members enrolled in Horizon NJ Health Medicaid, FIDE-SNP and MLTSS plans.
As part of this program, TurningPoint will conduct Prior Authorization & Medical Necessity Determination (PA/MND) reviews of certain cardiac services, orthopedic services and spine services (many of which include implantable devices), that are requested by participating Horizon NJ Health physicians when these services are to be rendered in one of the following settings:
- Ambulatory Surgical Center
- Physician's Office
TurningPoint will not conduct PA/MND reviews of services that are:
- Rendered in an observation setting or in the Emergency Room (ER). Services rendered in these settings do not require PA/MND.
- To be provided to members enrolled in ABD or MLTSS plans for whom Medicare is the primary payer.
TurningPoint will conduct PA/MND reviews of certain orthopedic, cardiac and spine services to:
- Determine that the services to be provided are considered medically necessary
- Ensure appropriate conservative therapies are attempted prior to invasive procedures
- Help to ensure that the most appropriate surgery is performed in the most appropriate setting using the most appropriate implant(s)/device(s)
- Help to improve provider best practices
Obtaining a pre-service PA/MND from TurningPoint will ensure that the services in question will be considered medically necessary.
As part of this program, TurningPoint will also review submitted professional and facility claims that include services included in the scope of this program. Services for which a pre-service PA/MND review was not performed that TurningPoint deems not medically necessary upon their review may not be eligible for coverage or payment by Horizon NJ Health. Horizon NJ Health reserves the right to adjust claims based on TurningPoint's recommendations.
TURNINGPOINT PROVIDER PORTAL
A variety of resources are available to you through the TurningPoint provider portal.
Access TurningPoint Through NaviNet
A new transaction - TurningPoint PA/MND Requests - has been added within the Workflows for this Plan section of the Horizon NJ Health plan central page.
Clicking this new NaviNet link will allow you to quickly and easily access the TurningPoint provider portal without having to sign in again.
Please note that to see and use this new transaction, users must be granted access by their Security Officer and they must also register with TurningPoint for portal access (see bullet below).
If you are already registered for the TurningPoint provider portal to manage services for your Horizon BCBSNJ patients, you DO NOT have to re-register to access information to manage services for your Horizon NJ Health patients. A single registration will provide access to both patient populations.
Medical Policy Criteria and Guidelines
TurningPoint manages and maintains the medical policy criteria and guidelines used to conduct PA/MND reviews as part of this program. To access this information, sign in to the TurningPoint provider portal and click the Policies tab within the menu bar. The medical policy criteria and guidelines used as part of this program can also be made available to you by calling TurningPoint at 1-833-436-4083, weekdays, 8 a.m. and 5 p.m., ET.
Provider Training Manual
To access training information about the Surgical and Implantable Device Management Program, please sign in to the TurningPoint provider portal and click the Help tab within the menu bar.
CPT® is a registered trademark of the American Medical Association.
NaviNet® is a registered trademark of NaviNet, Inc.
TurningPoint Healthcare Solutions, LLC supports Horizon NJ Health in the administration and utilization management review of certain orthopedic, cardiac and spine-related services for coverage. TurningPoint Healthcare Solutions, LLC is independent from, and not affiliated with Horizon NJ Health or the Blue Cross Blue Shield Association.