TurningPoint authorizations: Resources & information to support you

Earlier this fall, we launched our cardiac and MSK authorizations programs with TurningPoint to support our shared goals of improved safety, quality and affordability for our members, your patients. Nearly 6,000 cases (18% cardiac / 62% ortho / 20% spine) have been managed since the program’s soft launch in August.

We know challenges arise when a new program is launched. As your partner in care, we want to address a couple of common concerns we’ve heard.

Clinical policies

After thorough review, including approval by our Medical Advisory Committee (MAC) comprised of Priority Health network physicians, we adopted TurningPoint’s standard clinical policies for the procedures managed through this program.

These policies represent evidence-based guidelines that:

  • Promote appropriate surgery and implant utilization
  • Align with clinical best practices
  • Draw from the latest clinical literature and technologies

The American Academy of Orthopaedic Surgeons (AAOS), North American Spine Society (NASS), American College of Cardiology (ACC) and other national specialty societies review these clinical policies annually.

In alignment with these clinical policies, TurningPoint reviews requested procedures at the code level to ensure they match the documented surgical plan.

Access key clinical policy resources below:

  • TurningPoint clinical policies: To access the TurningPoint clinical policies, click here. You’ll be prompted to log into your Priority Health prism account and then immediately directed to the policies.
  • TurningPoint policy education: Refer to TurningPoint’s standard policy education resource which details what TurningPoint reviewers look for on topics including BMI, smoking, conservative therapy, coding and more.

Partial or adverse determinations

In the event you receive a partial approval or full denial, below are the options available to you to seek additional information and resolution:

Peer-to-peer

Schedule a peer-to-peer review. A TurningPoint subspecialized physician will meet with you to discuss the surgical plan and proposed procedures. TurningPoint requests three 2-hour windows of availability to support scheduling each peer-to-peer request. If your schedule doesn’t allow this, you can let their peer-to-peer coordinator know when discussing your availability.

For commercial and Medicaid members, this peer-to-peer discussion may impact the authorization determination pre- or post-denial. For Medicare members, peer-to-peer reviews may only impact the determination pre-denial and are educational when completed post-denial.

Find more information on page 20 of the TurningPoint provider training guide.

Appeal

You may also choose to submit a reconsideration request, or appeal, following an adverse determination. Learn about the appeal submission process and turnaround times on page 19 of the TurningPoint provider training guide.

Post-service change review

In the event procedures are added or changed in the operating room based on the intraoperative findings, you can submit a post-service change review (PSCR) form to TurningPoint with the operative notes and any relevant supporting clinical documentation. TurningPoint will review the added or changed procedures and update the authorization, as appropriate, if the operative notes / documentation show the addition or change was medically necessary. This PSCR process should be completed before submitting the claim.

Find more information on page 14 or the TurningPoint provider training guide.