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Update for Prior Authorization Requirements for Musculoskeletal Procedures - November 15, 2019

Date: 10/01/19

Prior authorization is required for the following Musculoskeletal surgical procedures in both inpatient and outpatient settings effective for service dates on and after November 15, 2019.

Orthopedic Surgical Procedures, including all associated partial, total and revision surgeries:

  • Knee Arthroscopy
  • Hip Arthroscopy
  • Femoroacetabular Arthroscopy
  • Unicompartmental/Bicompartmental Knee Replacement
  • Ankle Fusion
  • Shoulder Fusion
  • Wrist Fusion
  • Anterior Cruciate Ligament Repair
  • Knee Arthroplasty
  • Shoulder Arthroplasty
  • Elbow Arthroplasty
  • Ankle Arthroplasty
  • Wrist Arthroplasty
  • Hip Arthroplasty
  • Osteochondral Defect Repair
  • Acromioplasty and Rotator Cuff Repair

 

Spinal Surgical Procedures, including all associated partial, total and revision surgeries:

  • Spinal Fusion Surgeries (Cervical, Lumbar, Thoracic, Sacral)
  • Scoliosis
  • Disc Replacement
  • Laminectomy/Discectomy
  • Kyphoplasty/Vertebroplasty
  • Implantable Pain Pumps
  • Spinal Cord Neurostimulator
  • Spinal Decompression

Providers can access specific CPT codes that require prior authorization on Superior’s website by accessing the Prior Authorization Prescreen Tool

Superior HealthPlan previously provided notice of a new program to promote patient safety for Superior members undergoing Musculoskeletal Surgical procedures, and designed to work collaboratively with providers. The effective date for that program implementation has been modified to begin November 15, 2019.

The Surgical Quality and Safety Management Program includes administrative and clinical support tools, specialized peer to peer engagement, reporting and analytics, FDA recall tracking and monitoring, and provider performance incentives. This program is available to providers who serve Medicaid (STAR, STAR Health, STAR Kids and STAR+PLUS), CHIP, Allwell from Superior HealthPlan (HMO and HMO SNP) and Ambetter from Superior HealthPlan members.

As a part of this program, Superior will begin working with TurningPoint Healthcare Solutions, LLC to process prior authorization requests for medical necessity and appropriate length of stay (when applicable) for Musculoskeletal Surgical procedures. TurningPoint will begin accepting prior authorization requests on November 1, 2019 for service dates November 15, 2019 and after.  Prior authorization request for these services can be submitted to TurningPoint by fax, phone or web, as indicated below:

  • Web Portal access can be obtained by contacting TurningPoint by phone or email:
  • Telephonic Intake: 855-336-4391
  • Facsimile Intake: 833-409-5393

For more information regarding the Surgical Quality and Safety Management Program, refer to the article posted on July 1, 2019: Surgical Quality and Safety Management Program

We appreciate your support and look forward to your cooperation in assuring that Superior members receive high quality care in the appropriate setting for these surgical procedures.