20-470 Changes to Prior Authorization Process and Requirements for Musculoskeletal Surgical Procedures
Date: 06/08/20
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
TurningPoint must approve prior authorization requests for these surgical procedures
On August 11, 2020, certain musculoskeletal inpatient and outpatient surgical procedures will require prior authorization from TurningPoint Healthcare Solutions, LLC, rather than Health Net*.
This prior authorization change applies to, Medi-Cal fee-for-service (FFS) members ages 21 and over, Direct Network HMO, Point of Service (POS), and PureCare HSP Health Net members.
Capitated PPGs continue with their current process
Capitated participating physician groups (PPGs) delegated to approve prior authorization for musculoskeletal surgical procedures for their members will continue with their current process.
TurningPoint will accept requests as early as July 28, 2020
Refer to information below for musculoskeletal surgical procedures that require prior authorization from TurningPoint. If you have a prior authorization already approved through Health Net, Health Net will honor the approved prior authorization, subject to member eligibility.
Contact TurningPoint to submit prior authorization requests
Contact TurningPoint and not Health Net to request approval for musculoskeletal surgical procedures that require prior authorization.
TurningPoint Contacts
| Telephone | 1-855-332-5898, available Monday through Friday, 8 a.m. to 5 p.m., Pacific time |
| Fax | (949) 774-2254 |
| centenecaum@turningpoint-healthcare.com | |
| Website | TurningPoint Website |
| Training | Register for a webinar |
Other operations remain unchanged. As a reminder:
- In accordance with the Provider Participation Agreement (PPA), lack of prior authorization approval may result in nonpayment of claims.
- Emergency-related procedures do not require authorization.
Musculoskeletal surgical procedures that require prior authorization
Submit requests for prior authorization to TurningPoint for the following procedures.
Orthopedic surgical procedures (including partial, total and revision surgeries1)
- Acromioplasty and rotator cuff repair
- Ankle arthroplasty
- Ankle fusion
- Anterior cruciate ligament repair
- Elbow arthroplasty
- Femoroacetabular arthroscopy
- Hip arthroplasty
- Hip arthroscopy
- Hip resurfacing
- Knee arthroplasty
- Knee arthroscopy
- Knee replacement for unicompartmental or bicompartmental
- Osteochondral defect repair
- Meniscal repair
- Shoulder arthroplasty
- Shoulder fusion
- Wrist arthroplasty
- Wrist fusion
Spinal surgical procedures (including partial, total and revision surgeries1)
- Disc replacement
- Implantable pain pumps
- Kyphoplasty or vertebroplasty
- Laminectomy/discectomy • Spinal cord neurostimulator
- Spinal decompression
- Spinal fusion surgeries
TurningPoint contacts
- Register for a webinar.
- Submit an authorization on their website or by fax to (949) 774-2254.
- For questions call 1-855-332-5898, available Monday through Friday, 8 a.m. to 5 p.m., Pacific time.
Health Net contacts
Contact the Health Net Provider Services Center within 60 days at:
| Line of business | Telephone number | Provider portal |
|---|---|---|
| Health Net Employer Group HMO, POS, HSP, PPO2, & EPO2 | 1-800-641-7761 | provider.healthnet.com |
| IFP CommunityCare HMO, PPO2, PureCare HSP, PureCare One EPO2 | 1-888-926-2164 | provider.healthnetcalifornia.com |
| Medi-Cal | 1-800-675-6110 | provider.healthnet.com |
1 Effective August 11, 2020, musculoskeletal surgical procedures require prior authorization from TurningPoint Healthcare Solutions, LLC.
2 Continue to submit prior authorization requests to TurningPoint for EPO and PPO plans which started on November 1, 2019.