SurgicalDevice Provider Training Manual vFINAL · transparency into the criteria, giving physicians an opportunity to give clinical input within the marketplace regarding best practices

ProviderTrainingManualSurgicalandImplantable

DeviceManagementProgram

2|Page Proprietary&Confidential

PROVIDERTRAININGMANUAL

KeyContactInformation:BrandiPatterson StacyWolfProviderRelationsRepresentative VicePresident,ClientSolutionsPh:1-855-275-4500Ext.3271 Ph:[email protected] [email protected]

UTILIZATIONMANAGEMENT&PRECERTIFICATION:https://navinet.navimedix.com/Phone:1-833-436-4083|1-862-772-1003

TABLEOFCONTENTSKeyContactInformation......................................................................................................................2ProgramOverview...............................................................................................................................3

COVEREDPROCEDURES.....................................................................................................................................................4OPERATIONALPROCESS....................................................................................................................................................5OUT-OF-NETWORKPROCESS............................................................................................................................................5PROVIDERCUSTOMERSERVICE&ON-GOINGSUPPORT..................................................................................................6EVIDENCEBASEDCAREPATHS...........................................................................................................................................7

OperationalUserManual.....................................................................................................................9STEP1-HOWTOLOGIN...................................................................................................................................................9STEP2-HOMEPAGE&HOWTOSUBMITAREQUESTFORPRE-AUTHORIZATION............................................................10STEP3-HOWTOADDPHYSICIANINFORMATION............................................................................................................11STEP4-HOWTOADDPATIENTINFORMATION...............................................................................................................12STEP5-HOWTOADDPROCEDUREINFORMATION.........................................................................................................12STEP6-HOWTOADDDIAGNOSISINFORMATION...........................................................................................................13STEP7-HOWTOADDCLINICALINFORMATION..............................................................................................................14STEP8-HOWTOSELECTMANUFACTURER&PRODUCTTYPE.........................................................................................15STEP9-HOWTOSELECTTHEFACILITY............................................................................................................................16STEP10-HOWTOATTESTTOSURGICALPROTOCOLCONSIDERATIONS..........................................................................17STEP11-HOWTOVIEWTHESUMMARYOFTHEREQUESTENTERED..............................................................................18ADDITIONALPORTALSHORTCUTSANDHELPFULTIPS......................................................................................................19HELPTAB.........................................................................................................................................................................20REQUESTAUTHORIZATIONFORM...................................................................................................................................21QUICKREFERENCESHEET–CONTACTTURNINGPOINT..................................................................................................22



ProgramOverview

HorizonBlueCrossBlueShieldofNewJerseyhascontractedwithTurningPointHealthcareSolutions,LLC(TurningPoint) to offer a comprehensive strategy to managing the unique complexities of surgicalproceduresandmedicaldeviceutilizationthatwillenableyou, thePhysician, toensurean increase inthe safety and quality of care for your patients. The Surgical and Implantable Device ManagementProgram is designed to create a collaborative environment between Providers, TurningPoint andHorizon that promotes patient safety through the practice of high quality and cost-effective care forHorizon’smembers.

This Provider TrainingManualwill provide youwith anoverviewof theProgram implementation andoperational processes, and how to submit requests to TurningPoint for Prior Authorization and/orMedicalNecessityDeterminationspriortotheoccurrenceofthesurgicalprocedure.AsofDecember3,2018, the Program was launched for Horizon BCBSNJ’s Commercial Fully Insured Members forOrthopedic Surgical Procedures. TurningPoint looks forward to working with you on this importantinitiativetoimprovethequalityandsafetyofsurgicalproceduresforourmembers.

PROGRAMHIGHLIGHTSINCLUDE:ü AdministrativeToolstosupportanefficient,user friendlyprocess forproceduresrequiringprior

authorization, in addition to recommended medical necessity determinations (MND) forprocedures which do not require prior authorization. Easy and efficient post-proceduraldocumentation submissionwhichwill be sharedwithHorizon BCBSNJ to facilitate timely claimspayment.

ü Specialized“PeertoPeer”EngagementwhereaTurningPointphysician(fromthesamespecialty)engages the provider regarding authorization andMND requests that require additional clinicaldiscussiontovalidatetheclinicalappropriatenessoftheprocedurespecifictothepatient’sneedsandcurrentcondition.

ü ClinicalSupportToolstoassistinthetrackingandmonitoringofpatientoutcomesandeducationaround patient risks and preventive measures to better coordinate care for the member andreduceinfectionratesandcomplicationsduetopatientcomorbidities.

ü Device/Implant Management that provides evidence-based criteria ensuring clinicallyappropriate,highquality,costeffectivedeviceselection.

PROGRAMEXPANSIONUPDATES(EFFECTIVEJANUARY20,2020)MedicalNecessityDeterminationsforOrthopedicandCardiacSurgicalProcedureshasexpandedto includeHorizonBCBSNJ’sNewJerseyStateHealthBenefitsProgram(SHBP)/SchoolEmployees’HealthBenefitsProgram(SEHBP)plansfordatesofserviceonandafterJanuary20,2020.



COVEREDPROCEDURESPriorAuthorizationand/orMNDreviews,andtheappropriatelengthofstay(whenapplicable),hasbeendelegatedtoTurningPointforthefollowingsurgicalproceduresinbothinpatientandoutpatientsettings:

Note:AcurrentlistofrelevantCPTandHCPCScodesfortheaboveprocedurescanbeaccessedatHorizonBlue.com/turningpoint.

CoveredProcedures

HorizonCommercialFullyInsuredMembers

HorizonMedicareAdvantageMembers

HorizonSHBP/SEHBPMembers

Orthopedic BeganAcceptingRequestson11/19/2018ForDatesofService12/3/2018orlater

BeganAcceptingRequestson7/1/2019ForDatesofService7/15/2019orlater

BeginAcceptingRequestson01/02/2020ForDatesofService01/20/2020orlater

Cardiac BeganAcceptingRequestson7/1/2019ForDatesofService7/15/2019orlater

Notinscopeatthistime BeginAcceptingRequestson01/02/2020ForDatesofService01/20/2020orlater



OPERATIONALPROCESS

Theoperationalprocessesaredesignedtohelpimprovetheefficiencyandtimelinessofyourauthorizations,claimsvalidationandpaymentprocessing:

OUT-OF-NETWORKPROCESS

In an effort to support Horizon BCBSNJ’s member with their selection of Out-Of-Network Providers,TurningPoint’s intake team will help identify and track out-of-network providers that are providingmedicalservicesduringthesurgicalprocedureincludingbutnotlimitedtotheprimarysurgeon(whoisrequesting the procedure for MND), the facility provider, and any and all known assisting medicalproviderssuchasanassistantsurgeon,physician’sassistant,anesthesiologist,etc.HorizonBCBSNJhasanOut-Of-NetworkAttestationFormtohelpeducate thememberandnotate theiragreement tousetheirOut-Of-Networkbenefitfortheirupcomingprocedure.

ThisAttestationformisavailableviatheProviderPortalontheHelpmenu(HELPTAB).Additionally,asaprovider,youcancontactTurningPoint’sUtilizationManagementteamat1-833-436-4083,ifyouarenotaregisteredproviderportaluser.



PROVIDERCUSTOMERSERVICE&ON-GOINGSUPPORTOurProviderRelationsandUtilizationManagementteamsarededicatedtothecontinuedsupportofyourstaff.We’vedevelopedaseriesofmeetings,on-sitetrainings,andwebinaroptionstoengageyouandyourstaffduringtheimplementationphaseaswellasongoingaftertheinitiallaunchoftheProgram.EachmeetingisanopportunitytoengagewithbothTurningPointandHorizonBCBSNJregardingquestionsandconcernsyoumayhave,aswellashighlightthevaluetheProgramwillbringtoyourpracticeandpatients.

1) TheInitialProgramIntroductionincludesahigh-levelreviewoftheProgramcomponents,

highlightsthebenefitsandtoolsavailabletoyouandyourpractice,theauthorization/MNDandsystemfeatures,andincludesadiscussionforumwhereyouandyourstaffcanaskclarifyingquestionsandofferfeedbackregardingfutureenhancementsTurningPointandHorizonBCBSNJmaywanttoconsidertoimprovetheProgramafteritsinitiallaunch.

2) ClinicalDiscussionsregardingevidence-basedtreatmentguidelinesusedforPriorAuthorization

and/orMNDsareavailableuponrequest.ThisdiscussioncanincludekeymedicaldirectorsfrombothHorizonandTurningPoint’sclinicalteamsinordertoengagewiththeidentifiedkeyclinicalrepresentativesfromeachPhysiciangroup.Thisdiscussionoptionisofferedtopromotetransparencyintothecriteria,givingphysiciansanopportunitytogiveclinicalinputwithinthemarketplaceregardingbestpractices.

3) On-goingproviderstafftraining,andsupportbeginswithaninitialtrainingsessionofeach

physiciangroup’sstaffonTurningPoint’splatform,tools,andprocesses.Trainingmaterials,referenceguidesandsystemloginaccesswillalsobeprovidedatthistime.TurningPoint’steamprovidessupportwhenprovidersareinitiallyonboarded,whichincludesthestagingofauthorizationrequestsinthewebportalforsubmission,phoneand“ontheground”fieldrepresentativeswhoareavailableforimmediateon-sitetroubleshooting.Anyadditionaltrainingfornewpracticeofficestaffcanberequestedatanytime,asneeded.

4) LanguageAssistanceProgramsareavailableformembersorprovidersuponrequest.Toarrangefor

Oral and Written translation services, please call our Utilization Management Department at1-833-436-4083.

PleasefeelfreetocontactourProviderRelationsTeamforanyadditionalassistanceyouneed:

Name Phone# E-mailAddressGeographic

Territory/Network

BrandiPatterson 1-321-888-3271 [email protected] ProviderRelationsRepresentative



EVIDENCE-BASEDCAREPATHSTurningPoint has collaborated with Horizon BCBSNJ to develop our CarePath guidelines. A keycomponentof thedevelopmentprocess is theengagementofPhysician’sandpracticesata localandnationalleveltocorroboratethesupportingevidenceusedtodeterminetheappropriateCarePath(s)foreachprocedure.Asapartoftheprogram,physicianswillhaveanopportunitytoreviewtheCarePath’sthrough interactive round table discussions with both TurningPoint’s and Horizon BCBSNJ’s MedicalDirectors. Provider Relations representatives can be contacted for upcoming physician communityforumsaswellasschedulingindividualphysiciangroupdiscussionswithMedicalDirectors.

Whenavailable,ourCarePath’sarebaseduponNationalGuidelines.Otherwise,ourprocessreplicatesthestandardsutilizedbynationalassociations(suchastheAmericanAcademyof

OrthopedicSurgeons)tocreatetheirpolicies.

TOBEINCLUDEDASTUDYHADTOMEETTHEFOLLOWINGSELECTIONCRITERIA:

• Studywasspecifictothedevicetypeorprocedurebeingreviewed• Publishedinapeer-reviewedjournalduringorafter1966,inEnglish• Onhumanswithasampleof30ormorepatientspertreatmentgroup• Reportedon80%ofthepatientofthepatientpopulationofinterest• Studyresultswerepresentedquantitatively• Providedafullreportofaclinicalstudy• Studytreatmentfollowupperiodwas>4weeks• Atleast80%oftheenrolledstudypopulationwere19yearsofageorolder



• Foranyincludedstudythatused“paper-and-pencil”outcomemeasures(e.g.SF-36),onlythosethatwerevalidatedwereincluded

• “Paper-and-pencil”outcomesreportedbyasinglegroupofinvestigators(i.e.asinglestudy)wereexcluded

• Studywasinvivo

STUDIESWEREEXCLUDEDIFANYOFTHEFOLLOWINGCRITERIAWEREMET:• Studiesof“VeryLimited”evidencestrength• Retrospectivenon-comparativecaseseries,medicalrecordsreview,meetingabstracts,

historicalarticles,editorials,letters,andcommentaries• CaseseriesstudiesthatgavepatientsthetreatmentofinterestANDanothertreatment• Caseseriesstudiesthathadnon-consecutiveenrollmentofpatients• ControlledtrialsinwhichpatientswerenotstochasticallyassignedtogroupsANDinwhich

therewasheterogeneityinpatientcharacteristicsoroutcomesatbaselineANDwheretheauthorsdidnotstatisticallyadjustforthesedifferenceswhenanalyzingtheresults

• Compositemeasuresoroutcomes,eveniftheywerepatient-oriented• Caseseriesstudiesifnobaselinevalueswerereported• Studywasperformedoncadavers



OperationalUserManual

STEP1-HOWTOLOGIN

FromtheHorizonCorporateWebsite–Clickon“NaviNetSignIn”

1. Openyourpreferredwebbrowser,gotothefollowingwebaddress:https://navinet.navimedix.com/

2. ClicktheLoginNowbuttonanduseyourNaviNetloginandselectHorizonBCBSNJ3. OnceontheHorizonBCBSNJplancentralpageofNaviNet,selectTurningPointPA/MND

Requests…undertheReferralsandAuthorizationMenu

a. Ifyoudonotknowyour loginand/orpassword,pleasecontacteitherHorizonBCBSNJ

PhysicianServices(OR)[email protected].



STEP2-HOMEPAGE&HOWTOSUBMITAREQUESTFORPRE-AUTHORIZATION

1. MenuNavigationBar–Tohelpyounavigatetothedifferentfunctionalpageswithinthe

providerportal2. SearchField–Aquicksearchfeaturetohelpyoufindapreviouslyenteredrequestusingthe

treatmentrequestreferenceid,thepatient’sinformation,thephysicianinformation,oreventheprocedureitself.

3. YourLogininformation–Allowsyoutochangeyourpasswordandmanageyouruserprofileinformationbyclickingonthedownarrowfortheaccountmenu

4. AddRequest–AshortcuttotheRequestPagethatimmediatepullsupanewAddRequestform.

5. PracticeLocationDrop-DownList–Ifyourpracticehasmultipleoffices,theywillbelistedhereandcanbeusedtofilteryourHomePageviewtojustaspecificlocation.



6. Alerts – Important information regarding upcoming engagement opportunities, systemmaintenance,andhealthplanproviderupdatesforyourgroup.

7. Action Required – Shows all items requiring action specific to your group and can includeincompletedrafts,FDArecallsaffectingoneofyourpatients,additionalinformationrequested,andevenpostproceduresupportingdocumentationsuchasimplantlogsandpost-opreports.

8. Request Summary– Shows a snapshot of all your requests related to your group (or specificlocation,iffilteredon#5).ThesetilesarealsoshortcutstotheRequestsfunctionalpageandwillautomaticallysetaviewfiltertoshowonlythoserequestscountedwithinthattile.

STEP3-HOWTOADDPHYSICIANINFORMATION

1. AddRequestWizard–ShowingyouallthestepsintheAddRequestIntakeProcessand

highlightingwhichstepyouarecurrentlyon.2. DataEntryForm–Allfieldsrequiringinformationwillappearinthisareaasdrop-downmenus,

valuefieldsandselectionbuttons.3. SaveasDraft–Toenableausertosaveadraftoftherequesttobecompletedatalatertime.4. Previous/Next–Navigationbuttonsthatallowyoutomoveforwardandbackwardwithinthe

AddRequestDataEntryForm.5. AddPhysician/Practice/Location–Allowstheusertoenterproviderinformation,ifnot

availablewithinthedrop-downmenu.ThisinformationwillbevalidatedbyourProviderRelationsteampriortotherequestbeingfinalized.



STEP4-HOWTOADDPATIENTINFORMATION

1. AddRequestWizard–Willcontinuetoupdateasyouworkthroughtherequest.2. PatientLook-up–AllowsyoutosearchbyMemberIDORPatientNameandDataofBirth(DOB).3. AddPatient–Ifapatientisnotfound,itallowsyoutoenterthepatient’sinformationfor

eligibilityvalidationuponsubmissionoftherequesttoTurningPoint.4. PatientSelection–Showsthesearchresultsfromtheinformationenteredin#2.5. PatientInformation–Height/weightcanbeenteredusinginches/poundsORcm/kg.

STEP5-HOWTOADDPROCEDUREINFORMATION

1. ProcedureSelection–Allowsyoutofindyourprocedureusinga“plainlanguage”name(i.e.

TotalKneeReplacement).



a. Next,itwillfiltertheICD-9,ICD-10,orCPTCodesrelatedtothatprocedureforselectionb. Finally,itwillaskyoutoidentifythefacilitysettingwheretheprocedurewillbe

performed.

STEP6-HOWTOADDDIAGNOSISINFORMATION

1.Diagnosis–Thefiltermenuallowsyoutoselectadiagnosiscodebasedonpreviousproceduretypeselected.



STEP7-HOWTOADDCLINICALINFORMATION

1. PatientAge&BodyMassIndex(BMI)–Thesystemwillautomaticallycalculatethepatientsage

andBMIusing:a. ThebirthdateofthepatientfromtheeligibilityinformationprovidedbyHorizon

BCBSNJ.b. Height/weightinformationprovidedbyyouintherequest.

2. ClinicalInformation–Basedontheprocedureanddiagnosisselected,thesystemwillgeneratea setof clinical criteria that represents theminimumrecommendedclinical information tobecollectedonthepatientfortheprocedurerequested.

a. Insomecases, the informationwillbe required,basedonHorizonclinicalpoliciesandguidelines that will be applied to determine the medical necessity of the requestedprocedure.

b. Tomeetqualityandsafetycriteria,ALLclinicalinformationrequestedmustbeprovided.c. Thesystemwillpromptyouifinformationismissingbeforeallowingyoutocontinue

ontothenextstep.



STEP8-HOWTOSELECTMANUFACTURER&PRODUCTTYPE

1. SelectedDevice–Thestatusbarshowswhichdeviceiscurrentlyselected.2. DeviceSearch–Allowstheusertofilter/searchbasedonthemanufacturer,productline,or

implantmaterial/type.3. Product/DeviceSelection–Showsaresultinglistofproducts/devicesthatmaybeusedinthe

procedureidentifiedwithintherequest.Theseresultsarecurrentlysortedby“Quality”;however,eachcolumnheadingcanbeusedtore-sorttheresultinglist.



STEP9-HOWTOSELECTTHEFACILITY

1. SelectedFacility–Thestatusbarshowswhichfacilityiscurrentlyselected.2. DeviceSearch–Allowstheusertofilter/searchbasedonthefacilitynameorfacilitytype.3. FacilitySelection–Showsaresultinglistoffacilitiesthatmaybeusedintheprocedure

identifiedwithintherequest.Theseresultsarecurrentlysortedby“Quality”and“Avg.ProcedureCost”;however,eachcolumnheadingcanbeusedtore-sorttheresultinglist.

4. AverageProcedureCost-Diagramhighlightsspecificinformationsurroundingthefacilityselectedfortheprocedure.Keycomponentsinclude:

a. Thequalityinformationonthefacilityisavailableinpublicdomainandvalidated.b. Thegeographicproximitytotheselectedprovideroffice.c. SomeAverageAllowedcostrangesrelatedtothisfacilityspecifictoyourgroup.



STEP10-HOWTOATTESTTOSURGICALPROTOCOLCONSIDERATIONS

1. AttestationPagea. RecommendedApproach–Therecommendedapproachisbasedoffpatientspecific

criteria,aswellasevidence-basedguidelineswhichsuggestthatoneapproachmaybemoreclinicallyappropriateoveranother.

b. SurgicalConsiderations–Physicianattesttoperformingcertainpre,intra,andpost-operativebestpracticesforinfectionreductionandrecoveryprotocolsappropriateforthatprocedure.

c. LengthofStay-Recommendationsfortheappropriatelengthofstaywillbedisplayedatthetopofthispage.



STEP11-HOWTOVIEWTHESUMMARYOFTHEREQUESTENTERED

1. SummaryoftheRequest–Allowstheusertorevieworgobacktoaparticularsectionbyselectingthelink.

2. ProjectedOutcomeStatus–Displaysoutcomeasauthorizedorpendingreview.3. Print–Thisaddedbenefitallowstheusertoprintforyourrecords.



ADDITIONALPORTALSHORTCUTSANDHELPFULTIPS

1. RequestFilters–TheRequestspageallowsyoutoviewalltherequestsassociatedwithyourgroup(orspecificproviderlocationifselected).However,youhavetheabilitytofiltertherequestsbyvariouscriteriasuchasPatient,Physician,Diagnosis,etc.andmorethanonefiltercanbeaddedtonarrowyoursearchresults.

2. RequestResults–TheresultingRequestsarelist,bydefault,inchronologicalorderbyTreatmentRequestIDandyouhavetheabilitytoclickonanyrequesttoseethefulldetailoftheinformationsubmitted.

a. Eachcolumnheadingcanbeusedtore-sorttheresultinglist.b. TheApprovalStatusandPost-OpStatusarealsovisible.

3. Searchfield–Aquicksearchfeaturetohelpyoufindapreviouslyenteredrequestusingthetreatmentrequestreferenceid,thepatient’sinformation,thephysicianinformation,oreventheprocedureitself.

4. ActionSub-Menu–Allowsyoutoperformseveralactionsforeachrequest:a. ViewRequest.b. EditRequest(ifallowed);thisfunctionisdependentontheApprovalStatusofthe

request.c. Submitadditionaldocumentation(ifrequestedbyTurningPoint’sUMteam).d. PostProcedure,itallowsyoutosubmittherequestedimplantlogsandpost-operative

reportsasrequestedbyTurningPoint.



HELPTAB

TheHelpMenuprovideskeycontactinformationtohelpsupportyouandresolveissuesthatarise.TurningPointwillmanageandmaintainthemedicalpolicycriteriaandguidelinesthatwillbeusedtoconductPA/MNDreviewsaspartofthisprogram.Themedicalpolicycriteriaandguidelinesforcardiac/orthopedicserviceswillbeeffectiveforSHBP/SEHBPplansonJanuary20,2020.Orthopedicservicesarealreadyinscopeforfully-insuredandMedicareAdvantageplans.Cardiacservicesalreadyapplytofully-insured.

Toaccessthemedicalpolicycriteria:

• SelectHelpfromthemenubar• SelectMedicalPolicies

andClinicalGuidelineswithintheHelpfulArticlessection



REQUESTAUTHORIZATIONFORM



HOURSOFAVAILABILITY:MONDAY–FRIDAY*|8:00AM(EASTERN)TO5:00PM(EASTERN)*CalendarholidaysestablishedonayearlybasisbetweenTurningPointandHorizonBCBSNJwithon-callsupportprovidedonweekendsandholidaysasdeterminednecessary.

QUICKREFERENCESHEET–CONTACTTURNINGPOINT

PROVIDERRELATIONSSUPPORT:PH:1-833-436-4083|[email protected]

BrandiPatterson StacyWolfProviderRelationsRepresentative VicePresident,ClientSolutionsPh:1-855-275-4500Ext.3271 Ph:[email protected] [email protected]

UTILIZATIONMANAGEMENT&PRECERTIFICATION:WebPortal:https://navinet.navimedix.com/Phone:1-833-436-4083|1-862-772-1003SecuredSharedEmail:[email protected]

TECHNICALSUPPORT:PH:1-855-253-1100|[email protected]

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TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain orthopedic and cardiac services for coverage. TurningPoint Healthcare Solutions, LLC is independent from, and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.

Documents

SurgicalDevice Provider Training Manual vFINAL · transparency into the criteria, giving physicians an opportunity to give clinical input within the marketplace regarding best practices