TurningPoint - Surgical Quality and Safety Management Program

Sunshine Health is pleased to announce the launch of an innovative Surgical Quality and Safety Management program. The program is designed to collaborate with physicians to promote patient safety through high-quality and cost-effective care for Sunshine Health members undergoing cardiac surgical procedures.

Program highlights include:

• Administrative Tools to support an efficient, user-friendly authorization process for procedures requiring precertification, in addition to recommended medical necessity determinations for procedures that do not require precertification. Easy and efficient post-procedural documentation submission, which will be shared with Sunshine Health to facilitate timely claims payment.
• Specialized “Peer-to-Peer” Engagement where a TurningPoint physician (from the same specialty) engages the provider regarding authorization requests that require additional clinical discussion to validate the clinical appropriateness of the procedure specific to the patient’s needs and condition.
• Clinical Support Tools to assist in the tracking and monitoring of patient outcomes and education around patient risks and preventive measures to better coordinate care for the member and reduce infection rates and complications from patient comorbidities.
• Reporting and Analytics that give physicians and practice administrators greater visibility and transparency into their performance compared to the practice as a whole, and the rest of the market.
• FDA Recall Tracking and Monitoring to facilitate timely and consistent notification to the physician, patient and to Sunshine Health when a member has received or needs a revision surgery due to a Class I or II FDA device recall.

The effective date for this program varies based on product. See the chart below for important dates.

Prior authorization for medical necessity and targeted 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

• AICD/ICD
• Leadless Pacemaker
• Pacemaker
• Revision or replacement of ICD or Pacemaker
• CABG (non-emergent only)
• Coronary Angioplasty & Stents
•  Non-Coronary Angioplasty & Stents

TurningPoint’s Utilization Management & Precertification Contact Information

• Web: myturningpoint-healthcare.com
• Phone: 1-561-418-3256 | 1-855-415-7483
• Fax: 1-954-622-8034

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.
• Prior Authorization Scope Coding Handout (PDF)

We appreciate your support and look forward to your cooperation in assuring that Sunshine Health members receive high quality, cost-effective care for these surgical procedures.

Should you have any questions, please contact Sunshine Health Provider Services at 1-844-477-8313.