BHP Expanding Prior Authorization Program to Include Non-Emergent MSK
Effective January 1, 2024, Buckeye Health Plan is expanding our prior authorization program to include non-emergent MSK procedures. The expansion includes inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries for Buckeye Health Plan members.
We are pleased to announce a partnership with National Imaging Associates, Inc (NIA)* for utilization management services for non-emergent, Medical Specialty Solutions. In consideration of the aforementioned agreement, Buckeye Health Plan will terminate its current MSK program and utilization management efforts with TurningPoint as of December 31, 2023.
Under the terms of the agreement between Buckeye Health Plan and NIA, Buckeye Health Plan will oversee the MSK program and continue to be responsible for claims adjudication and medical policies. NIA will manage non-emergent outpatient interventional spine pain management services, and inpatient and outpatient MSK surgeries through the existing contractual relationships with Buckeye Health Plan.
Planned for a January 1, 2024, implementation, this announcement serves as notice under your participating Buckeye Health Plan Provider Agreement of changes to the program.
Providers may begin contacting NIA on January 1, 2024, to seek prior authorization for procedures scheduled on or after January 1, 2024.
The following outlines the specific procedures requiring prior authorization.
MSK Surgeries
Prior authorization will be required for the following non-emergent inpatient and outpatient hip, knee, shoulder, lumbar and cervical surgeries:
Hip
- Revision/Conversion Hip Arthroplasty
- Total Hip Arthroplasty/Resurfacing
- Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincer & labral repair)
- Hip Surgery – Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)
Knee
- Revision Knee Arthroplasty
- Total Knee Arthroplasty (TKA)
- Partial-Unicompartmental Knee Arthroplasty (UKA)
- Knee Manipulation under Anesthesia (MUA)
- Knee Ligament Reconstruction/Repair
- Knee Meniscectomy/Meniscal Repair/Meniscal Transplant
- Knee Surgery – Other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)
Shoulder
- Revision Shoulder Arthroplasty
- Total/Reverse Shoulder Arthroplasty or Resurfacing
- Partial Shoulder Arthroplasty/Hemiarthroplasty
- Shoulder Rotator Cuff Repair
- Shoulder Labral Repair
- Frozen Shoulder Repair/Adhesive Capsulitis
- Shoulder Surgery – Other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)
Lumbar
- Lumbar Microdiscectomy
- Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy)
- Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single & Multiple Levels
- Lumbar Artificial Disc Replacement
- Sacroiliac Joint Fusion
Cervical
- Cervical Anterior Decompression with Fusion –Single & Multiple Levels
- Cervical Posterior Decompression with Fusion –Single & Multiple Levels
- Cervical Posterior Decompression (without fusion)
- Cervical Artificial Disc Replacement
- Cervical Anterior Decompression (without fusion)
KEY PROVISIONS:
- It is the responsibility of the ordering physician to obtain prior authorization for all interventional spine pain management procedures and MSK surgeries outlined above.
- NIA does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those procedures listed above.
- Any Buckeye Health Plan prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery/procedure has met NIA’s medical necessity criteria.
Services other than MSK surgeries outlined above will continue to follow Buckeye Health Plan prior-authorization requirements for hospital admissions and elective surgeries.
We appreciate your support and look forward to your assistance in assuring that Buckeye Health Plan members receive MSK services delivered in a quality, clinically appropriate fashion.
We will provide additional information as we get closer to the implementation date. Should you have questions at this time, please contact Buckeye Health Plan Provider Services Department at 1-866-246-4359.
* Effective 1/20/2023, National Imaging Associates, Inc. is now a subsidiary of Evolent Health. Evolent Health and its affiliates and subsidiaries collectively referred to as “Evolent.”