Musculoskeletal surgeries and related procedures: New steps for determining whether prior authorization is required for Blue Cross commercial members

We added details to the Determining whether Blue Cross commercial members require prior authorization for musculoskeletal surgeries and related procedures (PDF) document that walk through the steps required to determine whether Blue Cross commercial is a member's primary coverage.

We did this because:

• When Blue Cross commercial is a member's primary coverage, Blue Cross Blue Shield of Michigan requires providers to submit a prior authorization request to TurningPoint Healthcare Solutions LLC for musculoskeletal surgeries and related procedures.
• When Blue Cross commercial isn't the member’s primary coverage, Blue Cross doesn't require you to do this. However, be sure to check the requirements for the member's primary coverage.

As a result of this difference and other considerations that are specific to Blue Cross commercial plans, it's important to know how to determine whether the service requires prior authorization.

Determining whether prior authorization is required for musculoskeletal procedures

The full process for determining whether a Blue Cross commercial member requires prior authorization for these procedures is:

1. Determine whether the procedure code requires authorization by TurningPoint. If yes…
2. Determine whether the member's primary coverage is through a Blue Cross commercial plan. If yes…
3. Determine whether the member requires prior authorization for musculoskeletal surgeries and related procedures.

See the document linked above for details on each piece of this process.

Additional information

For additional information about the TurningPoint musculoskeletal surgical quality and safety management program, see the Blue Cross Musculoskeletal services page or the BCN Musculoskeletal services page on this website.

As a reminder, TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

• Blue Cross commercial - All fully insured groups, select self-funded groups and all members with individual coverage
• Medicare Plus Blue^SM members
• BCN commercial members
• BCN Advantage^SM members

Posted: July 2021
Line of business: Blue Cross Blue Shield of Michigan