August 30, 2022
Wellcare is pleased to announce the launch of a new and innovative Cardiac 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 Wellcare members undergoing Cardiac Surgical Procedures.
Program Highlights Include:
- Administrative Tools. These will support an efficient, user-friendly request process for obtaining medical necessity prior authorizations for procedures which require pre-certification. Easy and efficient post-procedural documentation submission will be shared with Wellcare to facilitate timely claims payment.
- Specialized “Peer to Peer” Engagement. A TurningPoint physician (from the same specialty) engages the provider regarding authorization requests that require additional clinical discussion. This process validates the clinical appropriateness of the procedure specific to the patient’s needs and current condition.
- Clinical Support Tools. Elements will assist in the tracking and monitoring of patient outcomes and education around patient risks with preventive measures to better coordinate care for the member, reducing infection rates and complications due to patient comorbidities.
- Reporting, and Analytics. These provide physicians and practice administrators with 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. Both are designed to facilitate timely and consistent notification to the physician, patient, and to Wellcare when a member has received or needs a revision surgery due to a Class I or II FDA device recall.
This correspondence serves as notice under your Participating Wellcare Provider Agreement of these program changes, effective October 1, 2022. Physicians will be able to begin submitting requests to TurningPoint for Prior Authorization for Medicare Advantage Members for dates of service on or after October 1, 2022. While it is the responsibility of the rendering physician to obtain prior authorization, facility providers are encouraged to contact TurningPoint to verify that the prior authorization has been complete for Wellcare members prior to admission.
The program will include the following Wellcare Membership: Medicare Advantage, including DSNP plans.
Prior Authorization for medical necessity and appropriate length of stay (when applicable) has been delegated to TurningPoint Healthcare Solutions, LLC and will be required for the following surgical procedures in both inpatient and outpatient settings:
Cardiac Surgeries and Procedures:
Including all associated partial, total, and revision surgeries
| Cardiac Catheterization | Pacemaker |
| Coronary Angioplasty/Stenting | Pacemaker Revision or Removal |
| Implantable Cardioverter Defibrillator | Peripheral Revascularization |
| ICD Revision or Removal | Coronary Artery Bypass Grafting |
| Internal Cardiac Monitoring | Non-Coronary Angioplasty/Stenting |
| Leadless Pacemaker | Valve Replacement |
| Left Atrial Appendage (LAA) Occluders | WCD - Wearable Cardiac Defibrillator |
TurningPoint's Utilization Management and Precertification Contact Information:
- Web Portal Intake: www.myturningpoint-healthcare.com
- Telephonic Intake: NY: 1-917.398.3966|1-866.459.8334 ME: 1-339.309.7463|1-866.729.4894
- Facsimile intake: NY: 1-917.243.9602 ME: 1-207.352.5888
Key Provisions:
- 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 your claims
- Clinical Policies are available by contacting TurningPoint at 1-866-422-0800 for access to digital copies
Training:
Informational webinars are available! Please register at:
https://us06web.zoom.us/meeting/register/tZ0ufu-hqzwvHtMDVDK0Glv0Fs-Q-nQUS4ls
Dates for Webinars:
- September 13, 2022 10:00 AM
- September 15, 2022 1:00 PM
- September 20, 2022 2:00 PM
- September 21, 2022 10:00 AM
- September 22, 2022 3:00 PM
- September 27, 2022 11:00 AM
We appreciate your support and look forward to your cooperation in assuring that Wellcare members receive high-quality, cost-effective care for these surgical procedures.
Should you have any questions at this time, please contact Wellcare Provider Services Line at 1 (866) 422-5009.
