Provider Training Manual - Blue Cross Blue Shield Of Michigan

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Dear Provider,TurningPoint Healthcare Solutions, LLC (“TurningPoint”) on behalf of Blue Cross Blue Shield of Michiganand Blue Care Network is pleased to introduce you to our new Surgical Quality and Safety ManagementProgram (“Program”). The Program is designed to promote patient safety through the practice of highquality and cost-effective musculoskeletal care for Blue Cross’ PPO, Medicare Plus BlueSM PPO, BCNHMOSM and BCN AdvantageSM members. This Provider Training Manual will provide you with an overviewof the Program implementation and operational processes.Phase 1 of the Program is effective 07/01/2020, meaning surgeries with a date of service of 07/01/2020and beyond will be reviewed by TurningPoint.Phase two of the Program will be effective 01/01/2021, meaning surgeries with a date of service of01/01/2021 and beyond will be reviewed by TurningPoint. This expansion will include orthopedic andspinal procedures for Blue Cross’ PPO members, spinal procedures for Medicare Plus Blue members andpain management procedures for all lines of business.Note: TurningPoint will manage authorizations for musculoskeletal procedures for all Blue Cross’ PPOfully insured groups and for select Blue Cross’ PPO administrative service contract groups.TurningPoint looks forward to working with you on this important initiative to improve the quality andsafety of surgical procedures for Blue Cross and BCN members.PROGRAM HIGHLIGHTS INCLUDE: Specialized “Peer to Peer” Engagement where a TurningPoint physician (from the same specialty)engages the provider regarding authorization requests that require additional clinical discussion tovalidate the clinical appropriateness of the procedure specific to the patient’s needs and currentcondition. Administrative Tools to support an efficient, user-friendly authorization process for proceduresrequiring precertification, in addition to recommended medical necessity determinations forprocedures which do not require precertification. Easy and efficient post-procedural documentationsubmission will be shared with Blue Cross Blue Shield of Michigan to facilitate timely claims payment. Clinical Support Tools to assist in the tracking and monitoring of patient outcomes and educationaround patient risks and preventive measures to better coordinate care for the member and reduceinfection rates and complications due to patient comorbidities.Should you have any questions, the TurningPoint staff is available Monday through Friday, 8:00AM to8:00PM EST at (313) 908-6040.Regards,Eric PezziCEO

PROVIDER TRAINING MANUALKey Contact Information:Bethany FoxmanManager, Provider RelationsPh: 407-233-3429bfoxman@tpshealth.comStacy WolfSr. VP of OperationsPh: 805-896-7648swolf@tpshealth.comKayla HarrisProvider Relations RepresentativePh: 407-537-9786kharris@tpshealth.comUTILIZATION MANAGEMENT & PRECERTIFICATION:Web Intake: Provider Secured Services or http://www.myturningpoint-healthcare.comTelephonic Intake: (313) 908-6040 (833) 217-9670Facsimile Intake: (313) 879-5509TABLE OF CONTENTSKey Contact Information: . 3What We Do . 4DOCUMENT OVERVIEW. 4Program Overview . 5OPERATIONAL PROCESS . 6COVERED PROCEDURES . 6EVIDENCE-BASED CAREPATHS . 7CUSTOMER SERVICE & ON-GOING SUPPORT . 8Portal Registration . 10Operational User Manual. 13STEP 1- HOW TO LOG IN. 13Log in through Provider Secured Services . 13Log in through the TurningPoint website . 13STEP 2-HOME PAGE & HOW TO SUBMIT A REQUEST FOR PRE-AUTHORIZATION . 14STEP 3- HOW TO ADD PHYSICIAN INFORMATION. 15STEP 4- HOW TO ADD PATIENT INFORMATION . 16STEP 5- HOW TO ADD PROCEDURE INFORMATION . 17STEP 6- HOW TO ADD DIAGNOSIS INFORMATION . 17STEP 7- HOW TO ADD CLINICAL INFORMATION . 18STEP 8- HOW TO SELECT MANUFACTURER & PRODUCT TYPE . 193 PageProprietary & Confidential

PROVIDER TRAINING MANUALSTEP 9- HOW TO SELECT THE FACILITY . 20STEP 10- HOW TO ATTEST TO SURGICAL PROTOCOL CONSIDERATIONS . 21STEP 11- HOW TO VIEW THE SUMMARY OF THE REQUEST ENTERED . 22ADDITIONAL PORTAL SHORTCUTS AND HELPFUL TIPS . 23REPORTING TOOLS . 24HELP TAB: CONTACT CUSTOMER SERVICE . 24Authorization Request Forms . 25Quick Reference Sheet . 26What We DoTurningPoint’s Surgical Quality and Safety Management Program helps to improve the quality of care,safety and affordability of healthcare services for Blue Cross’ PPO, Medicare Plus Blue, BCN HMO and BCNAdvantage members. Our comprehensive Program integrates quality and safety measures related topatient comorbidities and risk factors, evidence-based utilization management pathways, site-of-serviceoptimization and specialized peer-to-peer engagement to promote the overall health management ofeach patient.DOCUMENT OVERVIEWThe intent of the Provider Training Manual is to give an overview of the scope, features and operationalprocesses of the Blue Cross Blue Shield of Michigan and TurningPoint Surgical Quality and SafetyManagement Program. The Program outlined in the Provider Training Manual is designed to workcollaboratively with your practice to promote and deliver improvements in the quality, safety and theaffordability of member care.This Program will utilize clinical guidelines that are based upon nationally recognized, evidence-basedcriteria for determining medical necessity in musculoskeletal surgical procedures. You can initiate a peerto-peer conversation with a TurningPoint Medical Reviewer at any time during the review process bycontacting TurningPoint’s Utilization Management Department at (313) 908-6040.This guide contains information essential to TurningPoint’s authorization process, lists of procedurescovered under the Program’s scope of services and an explanation of the portal features.4 PageProprietary & Confidential

PROVIDER TRAINING MANUALProgram OverviewTurningPoint offers a comprehensive strategy to managing the unique complexities of surgical proceduresand medical device utilization that will enable you, the Physician, to ensure an increase in the safety andquality of care for your patients. The foundation of this Surgical Quality and Safety Management Programis as follows:1. Treatment and “CarePath” Optimization - supporting you in selecting treatment plans that areevidence based, demonstrate high quality and optimize costs.Through the Surgical Quality and Safety Management Program, Blue Cross Blue Shield of Michigan andTurningPoint want to empower the collaboration between patients, physicians, and the health plan toimprove the quality of care and affordability of healthcare services. Blue Cross Blue Shield of Michiganand TurningPoint have worked together to develop a unique approach that creates value-addedhealthcare solutions for Physicians to help remove many of the traditional barriers that have preventedthe improvement of healthcare services for high-cost surgical and implantable device procedures.5 PageProprietary & Confidential

PROVIDER TRAINING MANUALOPERATIONAL PROCESSOur operational processes are designed to help improve the efficiency and timeliness of yourauthorizations, claims validation and payment processing:COVERED PROCEDURESThe following is a list of covered procedures that are included in the Program:MUSCULOSKELETALOrthopedic Surgical ProceduresIncluding all associated partial, total, and revision surgeries Knee ArthroplastyUnicompartmental/Bicompartmental KneeReplacementHip ArthroplastyShoulder ArthroplastyElbow ArthroplastyAnkle ArthroplastyWrist ArthroplastyAcromioplasty and Rotator Cuff RepairAnterior Cruciate Ligament RepairKnee ArthroscopyHip ResurfacingMeniscal RepairHip ArthroscopyFemoroacetabular ArthroscopyAnkle FusionShoulder FusionWrist FusionOsteochondral Defect Repair6 PageSpinal Surgical ProceduresIncluding all associated partial, total, and revision surgeries Spinal Fusion Surgeries Cervical Lumbar Thoracic Sacral ScoliosisDisc broplastySacroiliac Joint FusionImplantable Pain PumpsSpinal Cord NeurostimulatorSpinal Decompression Epidural Steroid InjectionFacet Joint InjectionNeurotomySacroiliac (SI) Joint Injection Pain Management ProceduresProprietary & Confidential

PROVIDER TRAINING MANUALEVIDENCE-BASED CAREPATHSTurningPoint has collaborated with Blue Cross Blue Shield of Michigan to develop our CarePath guidelines.A key component of the development process is the engagement of Physicians and practices at a localand national level to corroborate the supporting evidence used to determine the appropriate CarePath(s)for each procedure. As a part of the Program, physicians will have an opportunity to review the CarePathsthrough interactive roundtable discussions with both TurningPoint’s and Blue Cross Blue Shield ofMichigan’s medical directors. Provider Relations representatives can be contacted for upcoming physiciancommunity forums as well as scheduling individual physician group discussions with medical directors.When available, our CarePaths are based upon National Guidelines. Otherwise, our process replicatesthe standards utilized by national associations (such as the American Academy of OrthopedicSurgeons) to create their policies.TO BE INCLUDED A STUDY HAD TO MEET THE FOLLOWING SELECTION CRITERIA: Study was specific to the device type or procedure being reviewedPublished in a peer-reviewed journal during or after 1966, in EnglishOn humans with a sample of 30 or more patients per treatment groupReported on 80% of the patients of the patient population of interestStudy results were presented quantitativelyProvided a full report of a clinical studyStudy treatment follow up period was 4 weeksAt least 80% of the enrolled study population were 19 years of age or olderFor any included study that used “paper-and-pencil” outcome measures (e.g. SF-36), only thosethat were validated were included“Paper-and-pencil” outcomes reported by a single group of investigators (i.e. a single study)were excludedStudy was in vivo7 PageProprietary & Confidential

PROVIDER TRAINING MANUALSTUDIES WERE EXCLUDED IF ANY OF THE FOLLOWING CRITERIA WERE MET: Studies of “Very Limited” evidence strengthRetrospective non-comparative case series, medical records review, meeting abstracts,historical articles, editorials, letters and commentariesCase series studies that gave patients the treatment of interest AND another treatmentCase series studies that had non-consecutive enrollment of patientsControlled trials in which patients were not stochastically assigned to groups AND in which therewas heterogeneity in patient characteristics or outcomes at baseline AND where the authors didnot statistically adjust for these differences when analyzing the resultsComposite measures or outcomes, even if they were patient-orientedCase series studies if no baseline values were reportedStudy was performed on cadaversCUSTOMER SERVICE & ON-GOING SUPPORTOur Provider Relations and Utilization Management teams are dedicated to the continued support of yourstaff. A series of meetings, webinars, on-site trainings and symposiums to engage you and your staff willbe scheduled during the implementation phase as well as throughout the duration of the Program. Eachmeeting is an opportunity to engage with both TurningPoint and Blue Cross Blue Shield of Michiganregarding questions and concerns you may have, as well as highlight the value the Program will bring toyour practice and patients. Regularly scheduled open forum webinars will be offered by TurningPoint’smedical directors and Advisory Board covering current events relative to the marketplace. In addition,webinars will be scheduled as necessary, covering any software updates and or release notes.1) The Initial Program Introduction includes a high-level review of the Program components, highlightsthe benefits and tools available to you and your practice, the authorization process and systemfeatures, and includes a discussion forum where you and your staff can ask clarifying questions andoffer feedback regarding future enhancements TurningPoint and Blue Cross Blue Shield of Michiganmay want to consider to improve the Program after its initial launch.2) Clinical Discussions regarding evidence-based treatment plans. This discussion will include keymedical directors from both Blue Cross Blue Shield of Michigan and TurningPoint’s clinical teams toengage with the identified key clinical representatives from each Physician group and is intended topromote the opportunity for physicians to give clinical input within the marketplace regarding bestpractices.8 PageProprietary & Confidential

PROVIDER TRAINING MANUAL3) On-going provider staff training and support begins with an initial training session of each physiciangroup’s staff on TurningPoint’s platform, tools and process. Training materials, reference guides andsystem login access will also be provided at this time. TurningPoint’s team will provide support priorto 01/01/2021, which includes the staging of authorization requests in the web portal forsubmission, telephonic and “on the ground” field representatives available for immediate on-sitetroubleshooting and additional training as needed. After the Program launch, your practice willreceive frequent and regular communication from TurningPoint’s Provider Relations team viatelephonic and onsite visits to continue assisting you with any additional training needs or specificissues (technical or otherwise) that need to be resolved for the practice relative to the Program.4) Language Assistance Programs are available for members or providers upon request. To arrange forOral and Written translation services, please contact our Utilization Management Department at(313) 908-6040.Please feel free to contact our Provider Relations Team for any additional assistance you need:TurningPoint Provider Relations TeamTeam MemberStacy WolfSr VP of OperationsBethany FoxmanManager, Provider RelationsTeam Role: Provider RelationsKayla HarrisProvider Relations RepresentativeTeam Role: Provider RelationsContact InformationEmail: swolf@tpshealth.comDirect Line: 407.233.3483Cell Phone: 805.896.7648Email: bfoxman@tpshealth.comDirect Line: 407.233.3429Email: kharris@tpshealth.comOffice: 407.537.9786Provider Relations Support: BCBSMProviderRelations@tpshealth.com9 PageProprietary & Confidential

PROVIDER TRAINING MANUALPortal RegistrationHOW TO REGISTER FOR THE PORTALNote: If you have access to Blue Cross and BCN’s Provider Secured Services, you don’t need to registerwith TurningPoint for direct access to the provider portal through their website.1. Opening your preferred web browser, go to the following web . Click the “Register for Access” button10 P a g eProprietary & Confidential

PROVIDER TRAINING MANUAL3. Click on “Provider Portal Registration Template” to download and open the Excel spreadsheetthat will allow for you to include the practice name, demographic information and individualphysician’s information, along with all staff seeking access to the TurningPoint portal.11 P a g eProprietary & Confidential

PROVIDER TRAINING MANUAL4. Upon completion of the Provider Portal Registration Template, please email the TurningPointSupport Team at portalsupport@turningpoint-healthcare.com. Please include in your email thecompleted Provider Portal Registration Template and allow 24 – 48 hours for the registrationprocess to be completed.5. The TurningPoint Support Team will email you the username and temporary password for portalaccess.12 P a g eProprietary & Confidential

PROVIDER TRAINING MANUALOperational User ManualSTEP 1- HOW TO LOG INLog in through Provider Secured ServicesIf you have access to Blue Cross and BCN’s Provider Secured Services, you can access the TurningPointProvider Portal through the Provider Secured Services home page. To do this:1.2.3.4.Go to bcbsm.com/providers.Log in to Provider Secured Services.Click the Musculoskeletal service authorization through TurningPoint link.Enter your NPI.Log in through the TurningPoint website1. Opening your preferred web browser, go to the following web . Click the “Login Now” button and use your email address as your login name.a. This email address has been provided by your office administrator/manager. If you areunsure of your login name, please check with your immediate supervisor first beforecontacting TurningPoint for assistance.13 P a g eProprietary & Confidential

PROVIDER TRAINING MANUALb. If you do not know your login and/or password, please contact either your ProviderRelations Team contact or our IT helpdesk (portalsupport@turningpoint-healthcare.com)STEP 2-HOME PAGE & HOW TO SUBMIT A REQUEST FOR PRE-AUTHORIZATION1. Menu Navigation Bar – To help you navigate to the different functional pages within the providerportal2. Search field – A quick search feature to help you find a previously entered request using thetreatment request reference id, the patient’s information, the physician informa

processes of the Blue Cross Blue Shield of Michigan and TurningPoint Surgical Quality and Safety Management Program. The rogram outlined in the Provider Training Manual is designed to work P collaboratively with your practice to promote and deliver improvements in the quality, safety and the .

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