October 2022

TurningPoint to review site of care for select hip and knee surgeries for Blue Cross commercial members, starting Jan. 2

Action item

To determine whether Blue Cross commercial members require prior authorization for their hip and knee surgeries, follow these steps:

Log in to our provider portal (availity.com**).
Choose Patient Registration and then Authorizations & Referrals.
Click on Authorization Request.
Enter the requested information.

Availity Essentials will tell you whether you need to submit an authorization request for the member.

Note: Prior authorization isn’t required if Blue Cross coverage is secondary to Original Medicare.

For dates of service on or after Jan. 2, 2023, TurningPoint Healthcare Solutions LLC will review the site of care for select hip and knee surgeries as part of each prior authorization determination.

Based on medical necessity review, TurningPoint may approve prior authorization requests for select hip and knee surgeries only when scheduled in an outpatient setting.

This change applies to the following Blue Cross Blue Shield of Michigan commercial groups and members:

All fully insured groups
Select self-funded groups, including UAW Retiree Medical Benefits Trust non-Medicare members
All members with individual coverage

Note: Review the “Action item” at the top of this article to learn how to determine whether a Blue Cross commercial member requires prior authorization for a musculoskeletal procedure.

You must submit an authorization request for an inpatient admission (procedure code *99222) through the e‑referral system if both of these statements apply:

TurningPoint approves a prior authorization request for a hip or knee surgery in an outpatient setting.
The member experiences a change in condition that requires an inpatient admission.

Blue Cross or BCN will review the request using InterQual^® criteria. See the “Submit an inpatient authorization” section of the e-referral User Guide for more information.

Performing select hip and knee surgeries in outpatient settings is supported by evidence-based guidelines and the Centers for Medicare & Medicaid Services.

Reminder

TurningPoint already reviews the site of care for select hip and knee surgeries for Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members. We started reviewing the site of care in January 2022.

Additional information

We updated the Musculoskeletal procedure authorizations: Frequently asked questions for providers document to reflect this change.

For more information about the TurningPoint musculoskeletal surgical quality and safety management program, see these pages on the ereferrals.bcbsm.com website:

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

TurningPoint Healthcare Solutions LLC is an independent company that manages authorizations for musculoskeletal surgical and related procedures for Blue Cross Blue Shield of Michigan and Blue Care Network.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2021 American Medical Association. All rights reserved.