Musculoskeletal Management Program: Transition of Utilization Review from TurningPoint to NIA Effective for Service Dates beginning January 1, 2024

Date: 10/02/23

Effective January 1, 2024, Utilization review of musculoskeletal related services and procedures will transition from TurningPoint Healthcare Solutions, LLC, Texas URA #2395464, to Texas National Imaging Associates (NIA), Texas URA #5258.

Effective for service dates January 1, 2024 and after, prior authorization must be requested through NIA for applicable non-emergent, musculoskeletal program services listed below.

The Musculoskeletal program is consistent with industry wide clinically appropriate quality of care standards to ensure appropriate utilization of resources for Superior Medicaid (STAR, CHIP, STAR+PLUS, STAR Kids, STAR Health), STAR+PLUS Medicare-Medicaid Plan (MMP), Wellcare by Allwell (Medicare HMO and HMO SNP) and Ambetter from Superior HealthPlan (Marketplace) members.

The Musculoskeletal program services and procedures that will be managed by NIA include outpatient Interventional Pain Management (IPM) services (sympathetic nerve blocks, spinal cord stimulators) and nonemergent inpatient and outpatient hip, knee, shoulder, lumbar and cervical surgeries. The procedure codes that are subject to prior authorization for these services and procedures can be found by visiting the Superior, Ambetter, MMP and Wellcare webpages.

There will be no change to claim submission requirements or inpatient notification of facility admission and elective inpatient admission prior authorization requirements.

KEY PROVISIONS:

• The ordering physician is responsible for obtaining authorization prior to performing the procedures and services listed above.
• Providers may begin contacting NIA on December 18, 2023 to request prior authorization for procedures scheduled for dates of service on or after January 1, 2024.
• Prior authorization requests for dates of service prior to January 1, 2024 must continue to be requested through TurningPoint.
  
• Prior authorization will not be required, for the procedures listed above, when emergent or inpatient.

Providers will receive additional information through provider training activities including:

• Provider announcements located on Superior’s Provider News and Information webpage and Superior’s Provider Newsflash.
• Updated provider manuals located on Superior’s Training and Manuals webpage.
• New provider education events (face-to-face and web-based) located on Superior’s Provider Training Calendar.  

For questions, please contact your assigned Superior Account Manager.