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MMP Expansion of TurningPoint Ear, Nose and Throat Surgery and Sleep Study Management Program

Date: 04/05/21

Effective July 5, 2021, Superior HealthPlan will expand the Ear, Nose and Throat (ENT) Surgery and Sleep Study Management Program for STAR+PLUS Medicare-Medicaid Plan (MMP) members. The program is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for members undergoing ENT surgeries and sleep study procedures.

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 ENT surgeries and sleep studies.

Please note: This program is launching May 1, 2021 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. For additional details, please reference the previously posted article.

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 patient outcomes, education around patient risks, preventive measures to better coordinate care for members and reducing infection rates and complications due to member 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.

Physicians will be able to submit requests to TurningPoint for prior authorization beginning on June 21, 2021 for dates of service on or after July 5, 2021. Prior authorization will be required for the following ENT surgeries and sleep studies performed in the inpatient, outpatient, physician’s office and in-home settings:

Ears, Nose and Throat (ENT) Surgeries

  • Tonsillectomy with or without adenoidectomy
  • Sinus surgery
  • Rhinoplasty and septoplasty
  • Laryngoscopy and laryngoplasty
  • Cochlear implant device
  • Tympanostomy and tympanoplasty
  • Thyroidectomy and parathyroidectomy
  • Balloon dilation esophagoscopy

Sleep Study Procedures

  • Polysomnography
  • Multiple sleep latency and maintenance of wakefulness testing
  • Actigraphy
  • Home sleep study

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.

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 ENT surgeries and sleep studies.