Horizon Brief Notes: PA/MND Reviews for Spine Surgery Services Will Transition from eviCore to TurningPoint

See below Brief Notes from Horizon regarding the Musculoskeletal Program for Spine Surgery

Horizon BCBSNJ Brief Notes 
Applies to: Commercial Fully Insured and Self-Insured business

PA/MND Reviews of Spine Surgery Services Will Transition from eviCore to TurningPoint

Beginning January 18, 2022, Prior Authorization and/or Medical Necessity Determination (PA/MND) review requests for spine-related services that will be performed on and after February 1, 2022, must be submitted to TurningPoint Healthcare Solutions (TurningPoint). These reviews are currently performed by eviCore. This change will affect Horizon Blue Cross Blue Sheilds of New Jersey’s fully insured business and self-insured accounts that have opted into the Musculoskeletal Program for Spine Surgery.

Quality Care for Our Members

TurningPoint will review PA/MND requests and make clinical decisions based on its policies to help ensure treatment options are clinically appropriate and financially responsible. TurningPoint will support Horizon BCBSNJ’s members and their doctors and other health care professionals to achieve:

• Better surgical outcomes
• Faster recovery times
• Lower risk of infection and other complications
• High-quality care throughout the clinical episode
• Lower risk of additional surgery

What’s Not Changing

• Services provided in the observation setting or the Emergency Room do not require PA/MND review.
• Services that are determined to be not medically necessary are not eligible for coverage or payment. Horizon reserves the right to adjust claims based on TurningPoint’s recommendations.
• Horizon’s self-insured customers that have eviCore’s spine-related services will continue to pay the same per employee per month costs for TurningPoint’s spine-related services.
• eviCore will continue to review PA/MND review requests for pain management services.

In addition, there are no changes for Horizon’s self-insured customers that do not have eviCore’s spine-related services.

1 The transition to TurningPoint for management of spine-related services is subject to the approval of the New Jersey Department of Banking and Insurance. If regulatory approval is not obtained by February 1, 2022, the transition from eviCore to TurningPoint will be delayed, and additional communications will be issued.