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Expansion of TurningPoint Surgical Quality and Safety Management Program

Date: 01/29/21

Effective May 1, 2021, Superior HealthPlan will expand our Surgical Quality and Safety Management Program to include cardiac surgeries. The program is designed to work collaboratively with physicians to promote member safety through the practice of high quality and cost-effective care for Medicaid (STAR, STAR+PLUS, STAR Health and STAR Kids), CHIP, Allwell from Superior HealthPlan (HMO and HMO SNP) and Ambetter from Superior HealthPlan members undergoing cardiac surgeries.

As a part of this program, Superior will expand our partnership with TurningPoint Healthcare Solutions, LLC to process prior authorization requests for medical necessity and appropriate length of stay (when applicable) for certain cardiac surgeries.

Program highlights include:

  • Administrative Tools to support an efficient, user-friendly authorization process for procedures requiring precertification, in addition to recommended medical necessity determinations for procedures which do not require precertification. These tools allow for easy and efficient post-procedural documentation submissions, which will be shared with Superior to facilitate timely claim payments.
  • Specialized “Peer-to-Peer” Engagement where a TurningPoint physician, from the same specialty, engages the provider regarding authorization requests that require additional clinical discussion to validate the clinical appropriateness of the procedure specific to the patient’s needs and current condition.
  • Clinical Support Tools to assist in tracking and monitoring member outcomes, education around risks, preventive measures to better coordinate care and reducing infection rates and complications due to comorbidities.
  • Reporting and Analytics that gives providers and practice administrators greater visibility and transparency into their performance compared to the practice as a whole, as well as the rest of the market.
  • Food and Drug Administration (FDA) Recall Tracking and Monitoring to facilitate timely and consistent notification to the provider, member and Superior when a patient has received or needs a revision surgery due to a Class I or II FDA device recall.

Physicians will be able to submit requests to TurningPoint for prior authorization beginning on April 19, 2021 for dates of service on or after May 1, 2021. 

Prior authorization will be required for the following cardiac surgeries in both inpatient and outpatient settings:

  • Arterial procedures
  • Coronary angioplasty/stenting
  • Coronary artery bypass grafting
  • Implantable Cardioverter Defibrillator (ICD)
  • ICD revision or removal
  • Left atrial appendage occluders
  • Loop recorders
  • Non-coronary angioplasty/stenting
  • Pacemaker
  • Pacemaker revision or removal
  • Valve replacement
  • Wearable cardiac defibrillator

Please note:

  • Emergency-related procedures do not require authorization.
  • It is the responsibility of the ordering physician to obtain authorization.
  • Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of claims.

Below is a list of upcoming provider training events for the program: 

To find training opportunities, please visit Superior’s Provider Training Calendar.

For questions regarding this notification, prior authorization requirements, or impacted CPT codes, please contact TurningPoint by email at providersupport@turningpoint-healthcare.com or by calling TurningPoint Provider Support at 1-866-422-0800.

Additional program details will be communicated as they become available. We appreciate your support and look forward to your cooperation in assuring that Superior HealthPlan members receive high quality, cost-effective care for cardiac surgeries.