Surgical Quality and Safety Management Program

Date: 08/01/19

Effective October 1, 2019, Superior HealthPlan will launch a new and innovative Surgical Quality and Safety Management Program. The program is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for Superior members undergoing Musculoskeletal Surgical procedures.

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.

The Surgical Quality and Safety Management Program is available to providers who serve Medicaid (STAR, STAR+PLUS, STAR Health and STAR Kids), CHIP, Allwell from Superior HealthPlan (HMO and HMO SNP) and Ambetter from Superior HealthPlan members.

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 claims payment.
• 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 the patient and reducing infection rates and complications due to patient comorbidities.
• Provider Performance Incentives for providers who comply with program requirements to practice high quality, cost effective care.
• 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.
• FDA Recall Tracking and Monitoring to facilitate timely and consistent notification to the provider, patient 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 begin submitting requests to TurningPoint for prior authorization beginning on September 1, 2019 for dates of service on or after October 1, 2019. Prior authorization will be required for the following Musculoskeletal surgical procedures in both inpatient and outpatient settings:

Orthopedic Surgical Procedures

Including all associated partial, total and revision surgeries

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

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.
• Authorization requirements for facility and radiology may also be applicable.

Providers may access a detailed list of impacted CPT codes on TurningPoint’s Web Portal or by visiting Superior Healthplan's Prior Authorization page.

For questions regarding this notification, utilization management or precertification, and to submit prior authorization requests, please contact TurningPoint at:

• Web Portal Intake: TurningPoint Healthcare
• Telephonic Intake: 469-310-3104 | 855-336-4391
• Facsimile Intake: 214-306-9323

We appreciate your support and look forward to your cooperation in assuring that Superior members receive high quality cost-effective care for these surgical procedures.