Surgical and Implantable Device Management Program Orthopedic Services Frequently Asked Questions (2024)

Horizon BCBSNJ collaborates with TurningPoint Healthcare Solutions, LLC (TurningPoint) for the utilization management of certain services requiring the use of an implantable device, including specialized orthopedic surgeries (defined below; see question 4)

Through Horizon BCBSNJ's Surgical and Implantable Device Management Program, TurningPoint will conduct Prior Authorization & Medical Necessity Determination (PA/MND) reviews for certain specialized orthopedic surgeries that are requested by participating and nonparticipating physicians rendered in the following settings:

Inpatient
Outpatient
Ambulatory Surgical Center
Physician's Office

TurningPoint will not perform PA/MND for orthopedic services administered in an observation setting or Emergency Room (ER).

Members are participating in this program if they are enrolled in: a fully insured or level-funded commercial or Medicare Advantage (including Braven Health) plan/product; a plan/product offered through a self-insured Administrative Services Only (ASO) employer group that has that has elected to participate in this program including the State Health Benefit Program (SHBP)/School Employees' Health Benefit Program (SEHBP); or the Federal Employee Program® (FEP®).

TurningPoint conducts PA/MND reviews of services to be provided outside our local service area by health care professionals that participate with another Blue Cross and/or Blue Shield Plan. This applies to members enrolled in plans/products that include BlueCard® benefits or SHBP/SEHBP plans/products who receive services outside our local service area.

For FEP members, the TurningPoint program is only applicable to services provided within the state of New Jersey and that are being rendered by preferred health care professionals. FEP is excluded from the PA/MND review of services that are being rendered outside the state of New Jersey.

Below are answers to questions you may have about this program.

General

Q1. What is the Surgical and Implantable Device Management Program?
A1. Horizon BCBSNJ’s Surgical and Implantable Device Management Program, managed in coordination with TurningPoint, integrates evidence-based utilization management guidelines with clinical best practices, specialized peer-to-peer engagement, claims review and management, and advanced reporting and analytics to promote the overall health management of impacted members.

Q2. What is the relationship between Horizon BCBSNJ and TurningPoint?
A2. Horizon BCBSNJ has contracted TurningPoint for PA/MND reviews of select orthopedic surgeries requested by participating and nonparticipating physicians. It aims to help reduce surgical treatment variability, promote safety, improve the quality of care and outcomes and encourage patient support.

Q3. What services will TurningPoint perform as part of the Surgical and Implantable Device Management Program?
A3. TurningPoint provides utilization management (UM) reviews, First Level UM appeals processing, claim reviews and UM-related customer service support for certain specialized orthopedic surgeries (see question 4).

Q4. For what procedures/services does TurningPoint perform PA/MNDs as part of this program?
A4. TurningPoint will perform PA/MND reviews for medical necessity and appropriate length of stay (when applicable) for:

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

A list of the specific procedure codes included as part of this program may be accessed at HorizonBlue.com/turningpoint Coding is subject to regular updates/changes as CPT®/HCPCS coding is added or deleted.

Q5. How does TurningPoint manage the specialized orthopedic surgeries?
A5. TurningPoint reviews PA/MND requests in accordance with the clinical medical necessity criteria and guidelines adopted by Horizon BCBSNJ. An approved PA/MND does not supersede member benefits, and as such, is not a guarantee of payment for services provided.

Q6. What Horizon BCBSNJ plans/products are included in the scope of this program?
A6. Members are included in this program if they are enrolled in fully insured or level-funded plans/products listed below, or if they are enrolled in these plans/products through a self-insured Administrative Services Only (ASO) employer group that has that has elected to participate in this program.

Advantage EPO
Direct Access
EPO
FEP (as of June 28, 2021)
HMO
Indemnity
Medicare Advantage (including Braven Health Plans)
OMNIA℠ Health Plans
PPO
POS
SHBP/SEHBP

Q7. What plans/products are NOT included in the scope of this program?
A7. Members enrolled in the following plans/products are NOT included in the scope of this program:

Medigap
Horizon NJ Health
Horizon NJ TotalCare (HMO SNP)
Self-Insured ASO (Administrative Services Only) employer groups

You can look at the back of the member’s ID card to determine whether the plan is self-insured Administrative Services Only (ASO) or fully insured. A self-insured ASO member ID card will state, “Horizon BCBSNJ provides administrative services only and does not assume any financial risk for claims.” A fully insured member’s ID card will not have that message. Please always verify member benefits, as it may be possible that the most current ID card is not presented at the time of service.

Q8. How can I check the benefits of my Horizon BCBSNJ patients?
A8. You may review member benefit information on Availity Essentials. Simply log in to Availity Essentials, select Payer Spaces and then select Horizon BCBSNJ. Then select Eligibility and Benefits Inquiry from within the Patient Registration tab.

Q9. Are participating and nonparticipating health care professionals included in this program?
A9. Yes. Participating and nonparticipating health care professionals in and out of New Jersey and are included in the program.

Q10. For what service dates must I obtain PA/MND for these specialized orthopedic surgeries?
A10. You should contact TurningPoint to request a PA/MND for these select specialized orthopedic surgeries for fully insured and SHBP/SEHBP members. PA/MND review will apply for FEP members for in-scope procedures performed on or after June 28, 2021.

Health Care Professionals

Q13. When should I request a PA/MND from TurningPoint?
A13. You should request a PA/MND review for any proposed course of treatment involving the specialized orthopedic surgeries included as part of this program (see question 4).

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

TurningPoint will review professional and facility claims submitted for services included as part of this program. 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.

Q14. I submitted a PA/MND request. What will happen next?
A14. There are three possible outcomes as of a result of the PA/MND review:

Approved: The complete treatment requested meets the criteria for medical necessity.
Partial Approval: Only a part of the treatment requested is approved and the remainder is denied.
Denied: The complete treatment does not meet clinical criteria and is denied.

For Inpatient Admissions: PA is required as determined by the member's benefits.
For Outpatient Services: PA is required as determined by the member’s benefits; where member benefits do not require a PA, pre- and post-service MND apply.

Q15. Which specialized orthopedic surgeries are included as part of this program?
A15. A list of the procedure codes of the specific specialized orthopedic surgeries included as part of this program is available. Please refer to question 4 or visit HorizonBlue.com/turningpoint.

Q16. How often is the list of specialized orthopedic surgeries updated?
A16. The list of codes included as part of this program is updated annually, or more frequently, if necessary. Before calling for a PA/MND request, visit HorizonBlue.com/turningpoint for the most updated listing. A notice will be posted regarding any changes to the list on HorizonBlue.com/providernews.

Q17. How can I obtain the orthopedic medical policy criteria and guidelines for members enrolled in plans that are included in this program?
A17. Please review the information within this program’s Medical Policy Criteria and Guidelines webpage.

Q18. Where can I find Horizon BCBSNJ’s medical policy criteria and guidelines for orthopedic services located for members enrolled in plans that are not included in the program?
A18. Horizon BCBSNJ’s medical policy criteria and guidelines for orthopedic services for members enrolled in plans that are not included in this program can be accessed by visiting HorizonBlue.com/medicalpolicy.

Q19. How did Horizon BCBSNJ make health care professionals aware of this program?
A19. Horizon BCBSNJ:

Mailed certified letters to hospitals 90 days prior to the program’s original implementation date for each line of business as applicable.
Posted an announcement on HorizonBlue.com/providernews 90 days prior to the program's original and expanded effective date.
Updated the Surgical and Implantable Device Management Program web page at HorizonBlue.com/turningpoint.
TurningPoint will offer ongoing education and support to health care professionals and facilities. For questions about the Surgical and Implantable Device Management Program, call TurningPoint at 1-833-436-4083.

Q20. When is this program effective for orthopedic services?
A20. Horizon BCBSNJ collaborates with TurningPoint for certain specialized orthopedic surgeries many of which may require the use of an implantable device. Please refer to question 6 for members included in this program.

Prior Authorization/Medical Necessity Determination (PA/MND)

Q21. When should a health care professional obtain a PA/MND?
A21. A health care professional should request a PA/MND review upon determining whether the patient’s treatment plan includes any of the specialty orthopedic surgeries included within this program. It’s important that an approved PA/MND is obtained prior to delivery of the services to ensure coverage.

TurningPoint will review professional and facility claims submitted for services included as part of this program (for FEP, for dates of service on and after DATE). 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.

Q22. How does a health care professional initiate a PA/MND?
A22. A health care professional can initiate a PA/MND by one of the following methods:

You may log on to Availity Essentials to initiate a PA/MND for cardiac services. In the Availity Essentials navigation bar, select Patient Registration and then select Authorizations & Referrals. On the Authorizations & Referrals page, select Authorization Request. Health care professionals who do not have access to Availity may submit a request via www.myturningpoint-healthcare.com. You must register to obtain access credentials to the web portal by calling TurningPoint at 1-833-436-4083.
Health care professionals may also call TurningPoint at 1-833-436-4083. For urgent requests, you must inform the Call Center Specialist that the request is URGENT to receive an expedited response.
If you call Horizon BCBSNJ’s prior authorization line regarding one of the procedures within the Surgical and Implantable Device Management Program, you will be transferred to TurningPoint for their PA/MND review of the specialized orthopedic surgery being requested.

Q23. What is the best method for requesting a PA/MND?
A23. The quickest and most efficient method to submit a PA/MND is through Availity. Log on to Availity Essentials and, in the Availity Essentials navigation bar, select Patient Registration and then select Authorizations & Referrals. On the Authorizations & Referrals page, select Authorization Request.

Health care professionals who do not have access to Availity may submit a request via www.myturningpoint-healthcare.com. You must register to obtain access credentials to the web portal by calling TurningPoint at 1-833-436-4083.

You may also call TurningPoint at 1-833-436-4083.TurningPoint medical professionals are on call 24 hours a day, seven days a week at the same phone number.

The on-call staff member will respond to cases involving urgent care usually within an hour.
TurningPoint will respond to cases involving non-urgent care within one business day.
All calls left with the answering service after hours will be addressed within one business day. All emails also will be addressed within one business day.

Q24. What information is necessary to obtain a PA/MND?
A24. The following minimum information is requested when a PA/MND request is submitted:

Health care professional information, including any assistant or co-surgeon planned to be used
Facility information and anticipated surgery date
Health plan information
Member information
Requested procedures/diagnosis
Clinical information
1. History of Present Illness (HPI)
2. Attempted Conservative Therapies (including physical therapy notes)
3. Radiographic Findings
4. Documented Surgical Plan
Device product type (if known and if applicable)
Device manufacturer information (if known and if applicable)
The names of any out-of-network health care professionals (co-surgeon, assistant surgeon, anesthesiologist, facility, etc.) to be used in the surgery

Q25. What is the ordering/rendering health care professional’s responsibility?
A25. The ordering/rendering health care professional must obtain the PA/MND and supply all of the demographic and clinical information. If a PA/MND is not obtained prior to rendering services, claim payment may be delayed or denied pending completion of a post-service MND review. If the rendering health care professional, who is not the ordering health care professional, calls TurningPoint to initiate a PA/MND, TurningPoint will contact the ordering health care professional to obtain the necessary clinical information.

The clinical information must be provided regardless of whether the ordering and the rendering health care professional are the same.

Q26. If a co-surgeon is required for a planned specialized orthopedic surgery procedure, what do I need to do?
A26. The rendering health care professional MUST indicate if an assistant or co‐surgeon is required for the requested specialized orthopedic surgery. The health care professional must provide TurningPoint with the assistant or co-surgeon’s name, Tax Identification Number (TIN) and Horizon BCBSNJ participation status.

Horizon BCBSNJ expects its participating primary surgeons to use the services of an assistant surgeon participating in our network when they are medically necessary in the performance of any specialized orthopedic surgery. In the event that a nonparticipating assistant surgeon is used, you must inform the member of the financial impact it may have on the member’s out-of-pocket costs.

Q27. How will TurningPoint notify me about the PA/MND determination?
A27. Approved determination: TurningPoint will call the requesting practitioner’s office to advise them of an approved determination made on the request. The physician, facility and member will receive an approval letter regarding the PA/MND request.

Adverse determination: TurningPoint will call the requesting physician’s office to explain the rationale for the denial. TurningPoint offers the physician the opportunity to send in additional information for reconsideration, or the opportunity to schedule a peer-to-peer conversation with the TurningPoint reviewer to discuss the denial.

Following this call, if the determination has not been changed as a result of the reconsideration, TurningPoint will send an adverse determination notification letter to the provider, member and facility, (where appropriate) detailing the rationale for the denied PA/MND. You can check status of the PA/MND determination by calling TurningPoint at 1-833-436-4083.

Q28. May I schedule a peer-to-peer conversation to discuss an adverse determination?
A28. Yes, TurningPoint offers physicians the opportunity to call TurningPoint at 1-833-436-4083 to schedule a peer-to-peer conversation with the TurningPoint reviewer to discuss an adverse determination.

Q29. Is an approved PA/MND review a guarantee of payment?
A29. No. An approved PA/MND is not a guarantee of payment. Claims submitted for these services will also be subject, but not limited to, the following:

Member eligibility at the time services are provided
Benefit limitations and/or exclusions
Appropriateness of codes billed
Horizon BCBSNJ’s claims reimbursem*nt policies

Q30. Are clinical trials part of this program?
A30. No. Clinical trials are not a part of this program. TurningPoint will handle PA/MND requests for investigational clinical trials if the member is participating in a national clinic trial with the exception of cancer clinical trials. PA/MND for cancer clinical trials will be handled by Horizon BCBSNJ. Please call Horizon BCBSNJ’s Complex Case Management department at 1-888-621-5894, option 2 for clinical trials.

Q31. What is the time frame for TurningPoint to render a PA/MND decision?
A31. Non-urgent PA/MND requests will be completed as soon as possible based on the urgency of the case, but no later than three business days from receipt of all required clinical information. If medical information that is critical to determine medical necessity under our medical policy requirements is missing, TurningPoint will contact the practice to obtain the information needed to complete the review. The determination will be made no later than 15 days from receipt of the necessary clinical information. Urgent PA/MND requests will be completed as soon as possible based on the urgency of the case, but no later than 72 hours from receipt of the request. Please refer to question 24 for the minimum information, which should be presented when submitting a PA/MND request.

Q32. How can I check the status of a PA/MND?
A32. The status of a PA/MND may be reviewed by one of the following methods:

The rendering/ordering physician may log on to Availity to review the status of a submitted PA/MND request. Log on to Availity Essentials and, in the Availity Essentials navigation bar, select Patient Registration and then select Authorizations & Referrals. On the Authorizations & Referrals page, select Authorization/Referral Inquiry.
If you do not have access to Availity, you can review the status of a submitted PA/MND request via www.myturningpoint-healthcare.com. You must register to obtain access credentials by calling TurningPoint at 1-833-436-4083.
Call TurningPoint at 1-833-436-4083 to confirm the status of a PA/MND.

Q33. Does a PA/MND approval number expire?
A33. Yes. An approved PA/MND is valid for 90 days from the date of approval.

Q34. If I want to modify a request BEFORE the procedure occurs, do I need to notify TurningPoint to update the PA/MND?
A34. Yes. Call TurningPoint to notify them of any modification to your request prior to the procedure occurring. Modifications to a PA/MND request may be made up to one day before the date of service for the surgical procedure. TurningPoint may require a new review of the case for medical necessity and/or clinical appropriateness of the change depending on what change is being requested.

Q35. If I need to modify a request, or if there is a change in the surgical plan during the procedure, should I notify TurningPoint to update the PA/MND?
A35. No. If you received an approved PA/MND and the surgical plan changes during the procedure, submit the claim as per normal Horizon BCBSNJ policy. If additional information is required to perform a post-service medical necessity review because of the change, TurningPoint will contact you for the additional clinical information needed as part of Horizon BCBSNJ’s claims/claims appeals process.

Q36. What if a member is scheduled for a specialized orthopedic surgery and is admitted for the procedure, but does not have a PA/MND?
A36. If a Notice of Admission (NOA) is received, and there is no record of an approved PA/MND by TurningPoint on file, Horizon BCBSNJ will review the case as an inpatient authorization request and notify TurningPoint of the admission via secure email. TurningPoint will then contact the health care professional to obtain the appropriate medical records to perform a post service medical necessity review for the surgery.

Q37. What happens if TurningPoint receives a PA/MND request that is not within the scope of the Surgical and Implantable Device Management Program?
A37. If the request is determined to be out of scope, TurningPoint will forward the request to the Horizon BCBSNJ’s Utilization Management review team.

Claims

Q38. Should claims for services included as part of this program be submitted to TurningPoint?
A38. No. Continue to submit claims as you do currently. Claims submitted without an approved PA/MND review may be denied.

Appeals

Q39. How can I appeal denied PA/MND requests?
A39. TurningPoint will make a clinical determination for Level 1 medical necessity appeals. TurningPoint will send an appeal determination letter to the member and physician, update the authorization record and advise Horizon BCBSNJ of the review outcome. If the appeal is upheld, the appeal determination letter will include information regarding further appeal rights that are available.

For post-service medical necessity appeal received directly by Horizon BCBSNJ, Horizon BCBSNJ will confirm if TurningPoint conducted a pre-service review. If the case is denied due to an authorization/medical necessity pre-service review performed by TurningPoint, then Horizon BCBSNJ will redirect the appeal to TurningPoint for Level 1 appeal review.

Q40. How can I dispute a PA/MND denial?
A40. Generally, a health care professional may dispute a denial that was based on medical necessity by seeking an appeal by:

Calling TurningPoint at 1-833-436-4083, or
Submitting written appeals to:
- Attn: Appeals Dept.
  TurningPoint Healthcare Solutions, LLC
  1000 Primera Blvd.
  Suite 3160
  Lake Mary, FL 32746

Q41. How can I dispute a denial that is not related to a PA/MND?
A41. You may dispute a denied claims determination that is not related to a PA/MND (a decision not based on medical judgment) by calling: For fully insured, SHBP/SEHBP, Medicare Advantage (including Braven Health plan) members:
Horizon BCBSNJ’s Physician Services at 1-800-624-1110 or Facility Services at 1-888-666-2535, weekdays, 8 a.m. to 5 p.m., ET.
For FEP members, call 1-800-624-5078 during these same hours.

Q42. Who can a health care professional contact for more information about a PA/MND appeal they submitted?
A42. For an appeal involving a PA/MND, they should call TurningPoint at 1-833-436-4083. For a claim appeal not involving medical judgment, they can call Horizon BCBSNJ’s Provider Services at 1-800-624-1110.

Ancillary/Facility

Q43. Are impacted orthopedic practices/facilities aware they must obtain an approved PA/MND that covers both the procedure and the device used?
A43. Yes. Practices/facilities received notification about this program’s implementation either by U.S. mail or by viewing the information posted on HorizonBlue.com/providernews. TurningPoint is also holding education sessions about the program.

Q44. What is the ordering/rendering health care professional’s responsibility? What happens if the surgeon performing the procedure does not confirm that an approved PA/MND is obtained from TurningPoint?
A44. The ordering/rendering health care professional must obtain the PA/MND and supply all of the demographic and clinical information. If a PA/MND is not obtained prior to rendering services, claim payment may be delayed or denied pending completion of a post-service MND review. If the rendering health care professional, who is not the ordering health care professional, calls TurningPoint to initiate a PA/MND, TurningPoint will contact the ordering health care professional to obtain the necessary clinical information. The clinical information must be provided regardless of whether the ordering and the rendering health care professional are the same.

Q45. Will there be any financial impact to the facility if a device other than what was authorized by TurningPoint is used?
A45. The financial impact of using a device other than what was authorized by TurningPoint depends on the site of service.

INPATIENT FACILITY: There will be no financial impact if a device other than what was originally authorized by TurningPoint is used during a surgery performed in an inpatient hospital setting.

OUTPATIENT or AMBULATORY SURGERY CENTER (ASC): If a different device other than what was originally authorized by TurningPoint is used during a surgery performed in an outpatient or ASC setting, the device will be denied for no authorization. This situation would only occur if an authorization is required based on the member’s benefits in an outpatient or ASC setting.

If a device is changed, TurningPoint should be made aware of the change. The device must be FDA approved and meet TurningPoint’s medical necessity criteria for the clinical application. We encourage all facilities to verify what procedure and device has been approved by contacting the rendering physician’s office or TurningPoint BEFORE the procedure. Refer to question 48 for instructions.

Q46. What happens to the facility claim if the procedure is performed without a PA/MND approval?
A46. If a PA/MND is not obtained prior to rendering services, facility claim payment may be delayed or denied pending completion of a post-service MND review.

If TurningPoint's post-service review determines that a procedure is not medically necessary, the professional and facility claims for or related to that procedure will be subject to denial. Participating physicians and facilities may not bill Horizon BCBSNJ members for any such denied amounts.

To ensure there will be no delayed or denied claim payment, facilities should check with the ordering/rendering health care professional or TurningPoint BEFORE the procedure to ensure that the procedure and the device used (if applicable) has been reviewed and approved. Refer to question 48 for instructions.

The PA/MND requirement as part of this program does not impact/change a hospital’s existing authorization requirement for elective inpatient stays.

Q47. What if the physician changes the surgical plan or device based on the clinical condition during the surgery? Will it impact the facility claim?
A47. If the physician receives an approved PA/MND and the surgical plan or device is changed during the procedure, the physician/facility claim should be submitted according to Horizon BCBSNJ’s normal processes. If additional information is required to perform a post-service medical necessity review as a result of a change in information or surgical device, TurningPoint will contact the physician/facility for additional clinical information as part of Horizon BCBSNJ’s claims/claims appeals process. If there is a change to the device, TurningPoint will also review to ensure that the changed device is FDA approved for the clinical application.

An approved authorization is not a guarantee of payment. Payment is subject to member eligibility and all member and group benefit limitations, conditions and exclusions in effect at the time of the surgery, as well as Horizon BCBSNJ reimbursem*nt policies. Refer to question 45 for any financial impact associated with a change in device.

Q48. Who is responsible to determine whether the procedure and device were reviewed and approved by TurningPoint?
A48. TurningPoint will notify the physician of the approved procedure and device (as applicable). Physicians are instructed to inform the facility/operation room about the approval of the procedure/device to be used at the time of scheduling.

Rendering facilities are strongly encouraged to confirm the status of a PA/MND BEFORE a procedure is performed. Facilities may confirm the status of a PA/MND with the rendering physician, online or with TurningPoint as noted below.

You may log on to Availity to confirm the status of a submitted PA/MND request. Log on to Availity Essentials and, in the Availity Essentials navigation bar, select Patient Registration and then select Authorizations & Referrals. On the Authorizations & Referrals page, select Authorization/Referral Inquiry.
If you do not have access to Availity, you can review the status of a submitted PA/MND request via www.myturningpoint-healthcare.com. You must register to obtain access credentials by calling TurningPoint at 1-833-436-4083.
You may also call TurningPoint at 1-833-436-4083 to confirm the status of a PA/MND and to provide a specific area and contact within the facility to receive future approvals and denials.

Q49. If a device is not approved, will the surgery need to be canceled?
A49. The program is designed to offer PA/MND review in advance of a planned date of surgery to ensure coverage. Procedures that do not meet the medical necessity criteria, or if the physician selects a non-FDA approved device, will be denied.

Use of the Member Attestation for Use of an Out-of-Network Provider form

Important Note: This section is not applicable to FEP members

Q50. When should members complete the Member Attestation for Use of an Out-of-Network Provider form?
A50. The member should complete the Member Attestation for Use of an Out-of-Network Provider form if he/she is enrolled in a Horizon BCBSNJ plan that includes out-of-network benefits, and an out-of-network doctor, facility and/or other health care professional has been selected to participate in his/her upcoming procedure. This form is ONLY to be used for patients enrolled in Horizon BCBSNJ plans that include out-of-network benefits.

The Member Attestation for Use of an Out-of-Network Provider form is NOT to be used for services to be provided to members enrolled in plans that do not include out-of-network benefits (including, but not limited to, Horizon HMO plans, Horizon EPO plans, OMNIA℠ Health Plans and Medicare Advantage HMO plans).

Q51. Why do members need to complete the Member Attestation for Use of an Out-of-Network Provider form?
A51. Horizon BCBSNJ encourages the use of in-network doctors, facilities and other health care professionals to help members get the most out of their benefits and to help lower their out-of-pocket costs. If an out-of-network doctor, facility or other health care professional is chosen to participate in a procedure, it’s important that the member understands the financial impact of this decision.

When a member uses out-of-network benefits, in addition to being responsible for any out-of-network cost-sharing amounts (copayments, deductible and coinsurance amounts, as applicable), the member is also responsible for the difference between Horizon BCBSNJ’s allowance for eligible services and the out-of-network health care professionals’ total billed charges.

Q52. How will members be made aware that the Member Attestation for Use of an Out-of-Network Provider form should be completed?
A52. When TurningPoint receives a request for the pre-approval (or prior authorization) of services to be rendered by an out-of-network doctor, facility and/or other health care professional, the member will receive a letter requesting that the Member Attestation for Use of an Out-of-Network Provider form be completed. A copy of the form will be included. As always, we encourage members to use participating doctors, facilities and health care professionals to help reduce their out-of-pocket costs.

This content was last revised on January 13, 2022 and may be subject to change.

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Availity Essentials is a product of Availity, LLC. Availity, LLC has contracted with Horizon Blue Cross Blue Shield of New Jersey and its affiliates in the administration of the provider portal. Availity, LLC is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.

TurningPoint Healthcare Solutions, LLC is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in utilization management for certain specialized orthopedics services. TurningPoint Healthcare Solutions, LLC is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.

Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross Blue Shield Association. The Blue Cross® and Blue Shield® names and symbols, and BlueCard® and Federal Employee Program® (FEP®), are registered marks of the Blue Cross Blue Shield Association. OMNIA℠ is a service mark of Horizon Blue Cross Blue Shield of New Jersey. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey.