Orthopedic & Spinal Procedures (Turning Point)
Prior Authorization for medical necessity and appropriate length of stay (when applicable) has been delegated to TurningPoint Healthcare Solutions, LLC and will be required for the following surgical procedures in both inpatient and outpatient settings.
Please use the Pre-Auth Check Tool to confirm prior authorization reqeuirements, or contact TurningPoint for additional information.
Orthopedic Surgical Procedures
Including all associated partial, total, and revision surgeries
- Knee arthroplasty
- Unicompartmental/bicompartmenral knee replacement
- Hip arthroplasty
- Shoulder arthroplasty
- Elbow arthrosplasty
- Ankle arthroplasty
- Wrist arthroplasty
- Acromioplasty and rotator cuff repair
- Anterior cruciate ligament repair
- Knee arthroscopy
- Hip resurfacinjg
- Meniscal repair
- Hip arthroscopy
- Femoroacetabular arthroscopy
- Ankle fusion
- Shoulder fusion
- Wrist fusion
- Osteochondral defect repair
Spinal Surgical Procedures
Including all associated partial, total, and revision surgeries
- Spinal fusion surgeries
- Disc replacement
- Sacroiliac joint fusion
- Implantable pain pumps
- Spinal cord neurostimulator
- Spinal decompression
- Emergency-related procedures do not require authorization
- It is the responsibility of the ordering physician to obtain authorization
- Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claims.
Who is TurningPoint Healthcare Solutions, LLC?
TurningPoint Healthcare Solutions, LLC (TurningPoint) provides an innovative Musculoskeletal Surgical Quality and Safety Management Program which empowers the collaboration of patients, payers, and providers to improve the quality and affordability of healthcare services. Our comprehensive solution integrates evidence-based utilization management guidelines with clinical best practices, site of service optimization, specialized peer to peer engagement, device and recall management, claims review and management, innovative quality programs, and advanced reporting and analytics to promote the overall health management of each member.
What is the relationship between Health Net and TurningPoint?
Health Net has contracted with TurningPoint to provide an innovative solution to work collaboratively with providers, facilities and physicians to reduce surgical treatment variability, promote safety, quality of care improvements, and support for your patients. As part of this program, Health Net has delegated their utilization management function to TurningPoint for a limited scope of procedures (see FAQ question 5 for a detailed listing of procedures included in the scope of the program).
Which Health Net members are impacted?
Health Net Medicare Advantage PPO and HMO members
Health Net commercial (PPO, EPO, CommunityCare) members
Will new ID cards be issued to the appropriate members?
No new ID cards will be issued to the members. Providers will be redirected to TurningPoint by the Utilization Management Departments within Health Net. TurningPoint will also be actively engaged in the education of each provider practice to ensure they have the appropriate contact information to limit the number of redirections that need to take place.
What procedures will require prior authorizations?
Clinical coding specific to the procedures included in the program may be accessed at Medicare claims.
Codes affected for commercial claims can be found in the Provider Update from January 3, 2020. Please note the coding is subject to regular updates/changes as CPT/HCPCS coding is added or deleted.
What happens if TurningPoint receives a request that is not within the musculoskeletal scope above?
When TurningPoint receives each request for prior authorization, the procedure and medical codes are validated against the scope of services agreed upon between TurningPoint and Health Net. If the request received is determined to be out of scope, TurningPoint will forward the request onto the appropriate Utilization Review team within Health Net based on the member's eligibility plan product information.
What medical providers will be affected by this agreement?
All Musculoskeletal (Orthopedic, Spine, Neuro, and Pain Management) providers whose members fall under the enrolled plan names will be affected.
Do emergency room visits require a prior authorization from TurningPoint?
No, emergeny surgeries do not require a prior authorization from TurningPoint.
How do I obtain a Prior Authorization from TurningPoint?
Providers may initiate a prior authorization request through TurningPoint's portal at https://myturningpoint-healthcare.com or by calling TurningPoint at Toll Free: 1-844-245-6518 or Local: 971-300-0597. Providers can also initiate requests or send additional clinical information via fax at 971-285-4207. If a provider calls the Health Net pre-authorization line regarding one of the procedures within the TurningPoint scope of services, they will be transferred to TurningPoint.
What are TurningPoint's hours and days of operation?
TurningPoint is available 8:00am – 5:00pm PT Monday – Friday. In the event a provider needs to contact TurningPoint for prior authorization after hours or on weekends, TurningPoint has medical professionals on-call 24 hours a day, 7 days a week.
What information will be required to obtain a prior authorization?
The following minimum information is requested when a provider calls, faxes or utilizes the portal:
- Provider Information
- Facility Information & Anticipated Surgery Date
- Health Plan Information
- Member Information
- Requested Procedures/Diagnosis
- Clinical Information
- Device Product Type (if known)
- Device Manufacturer Information (if known)
How long will the prior authorization process take?
*Turnaround time shall not exceed listed timeframes
|Plan Product | Line of Business||Standard (Non-Urgent) TAT*||Expedited (Urgent) TAT*||Retrospective|
|Medicare Advantage||14 business days||72 hours||30 calendar days|
|Commercial||OR: 2 business days
WA: 5 business days
|OR: 72 hours or 2 business days - whichever is lesser
WA: 48 hours
Does obtaining a prior authorization number guarantee payment?
The authorization number 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 were provided
- Benefit limitations and/or exclusions
- Appropriateness of codes billed
- Medical Necessity review, if prior authorization does not occur
How long will the authorization approval be valid?
Prior authorizations are valid for 90 calendar days for outpatient procedures and 1 day for the day of planned admission.
Will TurningPoint be processing claims for Health Net?
No, TurningPoint Healthcare is not delegated to process claims. Providers should continue to submit claims as they do currently. Claims submitted without the approved authorization may be denied for payment.
Who is responsible for requesting the prior authorization?
The physician/provider's office who requests the procedure should request the prior authorization.
How are providers/members notified of the outcome of the prior authorization request?
Providers will be notified by a courtesy call regardless of the status of the request. The provider, facility, and member will (where appropriate) receive a notification determination letter regarding the request status along with supporting information. In addition, the member will receive a call specific to denied authorization.
If a provider wishes to modify a request, or if there is a change in the surgical plan during the procedure, does the office need to notify TurningPoint to update the authorization?
Yes, providers must call TurningPoint to notify them of any modification to request. Modifications to a preauthorization request must be communicated immediately following the date of service for the surgical procedure.
What happens if the TurningPoint medical review team denies the procedure?
Once an adverse determination is rendered, TurningPoint calls both the requesting provider office and the member to explain the rationale for the denial. When speaking with the provider's office, TurningPoint offers the physician the opportunity to schedule a peer to peer conversation with the TurningPoint reviewer. Following this call, TurningPoint will send notification letters to the provider, member, and to the facility (where appropriate), detailing the rationale for the denial and peer to peer directions.
What qualifications do the TurningPoint physicians have in order to review prior authorization requests?
TurningPoint employs Orthopedic and Spine physicians who have all held positions within the largest associations related to their specialties:
- Five former presidents of the American Academy of Orthopedic Surgeons (AAOS)
- The former Chairman of the Louisiana State University Medical Center's Orthopedic Department and University of Colorado's Orthopedic Department
- Two of AAOS's former Board representatives to CMS for all spine-related billing and coding changes
- The former president and a current Director of the American Board of Orthopedic Surgery
- Multiple past regional and state orthopedic association presidents, including the former president of the New Jersey Orthopedic Association
- Former Chief of Staff for the Houston Shriner's Children Hospital
What are the program components providers need to comply with in order to be eligible for TurningPoint's Enhanced Reimbursement Program (ERP)?
*Please note: Health Net will need to collect data for 12-24 months in order to evaluate and reward practices for Quality performance. The health plan will keep open, ongoing conversations with providers regarding details of the ERP.
Health Net, along with TurningPoint's Surgical Quality and Safety Management Program, rewards providers for improving the quality, safety, and affordability of healthcare services for Health Net's members. The program integrates quality and safety measures related to patient comorbidities and risk factors, evidence-based utilization management pathways, site of service optimization, specialized peer to peer engagement, FDA device and recall tracking and advanced reporting and analytics to promote the overall health management of each patient.
Quarterly operational metrics will be reported on, showing each physician and physician group their performance within and adherence to the program. To qualify for enhanced reimbursements, the physician must meet all the following three categories of criteria:
- Quality and Safety Criteria:
- Clinical Appropriateness of Procedure
- Surgical Procedure Best Practices
- Clinical Appropriateness of Device
- Quality Device Selection
- Site of Service Optimization Criteria:
- Optimized Surgical Setting
- Preferred Facility
- Procedure Documentation Criteria:
- Submission of Facility and Professional claims
- Submission of implant log (lot/serial)
- Submission of physician's operative notes
Whom do I contact with questions or any support needs regarding the program?
For questions regarding the TurningPoint Surgical Quality and Safety Management Program, or to set up an in-service with your practice, please call the toll-free number 1-866-422-0800 and you will be directed to a Provider Relations Specialist.