We’re enhancing TurningPoint surgical quality and safety management program to improve your experience

The Blue Cross Blue Shield of Michigan and Blue Care Network Utilization Management department is committed to enhancing your experience with the TurningPoint Healthcare Solutions, LLC surgical quality and safety management program. Since we implemented the program, we’ve made changes to several areas based on provider feedback.

We’ve recently made the following enhancements:

• Published the code substitutions that are available for musculoskeletal procedures
• Detailed the steps required to determine whether prior authorization is required for Blue Cross commercial members
• Simplified the process for requesting peer‑to‑peer conversations
• Clarified clinical documentation requirements
• Updated and added informational resources for the TurningPoint program

Keep reading to learn more…

Code substitutions for musculoskeletal procedures
In some situations, you may not know which orthopedic or spinal procedure will be required in advance of a surgery or the surgical plan may change intraoperatively. As a result, the procedure code TurningPoint authorized may not represent the procedure that was actually performed.

Prior to submitting claims for these procedures, you’ll need to determine whether you can substitute the code for the procedure that was performed for the code TurningPoint authorized. If you can substitute the code, you won’t need to contact TurningPoint to update the procedure coding.

To learn how to determine if the approved code allows substitutions and to view all codes that allow substitutions, see the Musculoskeletal procedure code substitutions for orthopedic and spinal surgeries document.

This document is available on the Musculoskeletal services pages of our ereferrals.bcbsm.com website.

Determining whether prior authorization is required for Blue Cross commercial members
We created a document that walks through the steps required to determine whether Blue Cross commercial members require prior authorization. The document is titled Determining whether Blue Cross commercial members require prior authorization for musculoskeletal surgeries and related procedures. It’s available on the Blue Cross Musculoskeletal services page of our ereferrals.bcbsm.com website.

Process for requesting peer-to-peer conversations
The steps that lead up to peer-to-peer conversations with TurningPoint vary depending on whether the member has coverage through a commercial product or through a Medicare Advantage product.

Commercial members (Blue Cross commercial or BCN commercial)
If TurningPoint denies an authorization request for a commercial member, you have two options for requesting a reconsideration of the denial:

• You can ask TurningPoint to review additional clinical documentation, you can provide clarifying details that are pertinent to the request or both. Submit the documentation, details or both in one of these ways:
• Through the TurningPoint Provider Portal
• By fax. Include a cover sheet that identifies the patient and send the fax to 313‑879‑5509 for joint and spine procedures or to 313‑483‑7323 for pain management procedures.
• You can request a peer‑to‑peer conversation to review the case with a physician. To do this, call 1‑833‑217‑9670. You’ll need to provide three dates when you’re available to meet. TurningPoint will schedule the conversation based on the dates you request.

You can request a reconsideration or a peer-to-peer conversation any time before providing services or filing an appeal with the health plan.

If you completed a reconsideration or peer-to-peer conversation and are dissatisfied with the decision, you may appeal.

Medicare Advantage members (Medicare Plus Blue℠ or BCN Advantage℠)
Before denying an authorization request, TurningPoint will make three attempts to notify you of its intent to deny any request that doesn’t meet medical necessity criteria. As part of this notification, TurningPoint will offer to schedule a peer‑to‑peer conversation. You’ll need to give TurningPoint three dates when you’re available to meet. TurningPoint will schedule the conversation based on the dates you requested.

If TurningPoint is unable to contact you, it’ll proceed with the authorization decision based on the information you provided with the authorization request.

Alternately, you can request a peer-to-peer conversation any time before providing services or filing an appeal.

For TurningPoint to consider information obtained during a peer‑to‑peer conversation when making an authorization determination, the peer‑to‑peer conversation must take place prior to the denial of an authorization request.

Note: If the peer‑to‑peer conversation takes place after TurningPoint denies the authorization request, TurningPoint can’t reverse the denial. In such cases, the peer‑to‑peer conversation is for informational purposes only.

Clinical documentation requirements
We recently published updated information about the clinical documentation you must include when submitting prior authorization requests to TurningPoint.

We updated or added information related to the specific clinical documentation requirements for:

• Conservative therapies
• Body mass index
• Smoking status
• Surgical plan

To view the updated requirements, see the Clinical documentation requirements for musculoskeletal procedures document. This document is available on the Musculoskeletal services pages of our ereferrals.bcbsm.com website.

Resources for the TurningPoint program
Resources are available to help you navigate the TurningPoint musculoskeletal surgical quality and safety management program.

We update these resources on a regular basis to provide you with the most current information.

To learn more, see Here are resources for TurningPoint musculoskeletal surgical quality and safety management program, also in this issue.