CurrentFidelis CarePolicy N/A

Fidelis Care Ears, Nose, & Throat (ENT) Surgeries Management Program

Notice to providers of a new ENT Surgeries Management Program administered in partnership with TurningPoint effective October 4, 2021 (pending NY approval). The program delegates prior authorization for specified ENT procedures across Fidelis Care product lines and provides contact/training and administrative processes.

Policy Summary

PayerFidelis Care

PolicyFidelis Care Ears, Nose, & Throat (ENT) Surgeries Management Program

Policy CodePolicy N/A

Change TypeProgram launch / prior authorization delegation

Effective DateOct 4, 2021

Next Review Date

Key ActionOrdering physicians must obtain prior authorization from TurningPoint for the listed ENT procedures to avoid potential claim denial or non-payment.

SourceLink

POLICY UPDATE CHANGES

Launch of a new ENT Surgeries Management Program in partnership with TurningPoint effective October 4, 2021.

9Procedures listed requiring authorization

1Program launch effective date (2021-10-04)

Program summary

Fidelis Care implemented the ENT Surgeries Management Program in partnership with TurningPoint to promote patient safety, high-quality, and cost-effective care; the program centralizes prior authorization for specified ENT procedures and became effective October 4, 2021. Services provided through the program include specialized peer-to-peer reviews with a TurningPoint physician, administrative and clinical support tools, FDA recall tracking and monitoring, and reporting and analytics to provide visibility into performance and support efficient authorization processes.

Key Program Facts

Effective date2021-10-04

StatusCURRENT

SubjectFidelis Care ENT Surgeries Management Program (TurningPoint partnership)

Scope summaryNotice to providers of a new ENT Surgeries Management Program administered in partnership with TurningPoint effective October 4, 2021 (pending NY approval). The program delegates prior authorization for specified ENT procedures across Fidelis Care product lines and provides contact/training and administrative processes.

Authorization requirement & scope

Procedures requiring prior authorization

Authorization will be required for the following procedures in inpatient, outpatient (physician's office), and in-home settings:

ALL of the following

Tonsillectomy and/or Adenoidectomy
Rhinoplasty, Septoplasty
Sinus Surgery
Laryngoscopy / Laryngoplasty
Cochlear Implant (hearing)
Tympanostomy / Tympanoplasty / Myringotomy
Balloon Dilation Esophagoscopy
Thyroidectomy / Parathyroidectomy
Functional Endoscopic Sinus Surgery

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Exemptions / Not requiring authorization

ANY of the following

Emergency related procedures do not require authorization

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This is an administrative program that delegates prior authorization to TurningPoint across Fidelis Care product lines; ordering physicians must obtain authorization from TurningPoint for the listed ENT procedures prior to performing them, and providers should verify authorization has been obtained to avoid claim denials or non-payment.

What providers must do

Prior Authorization

Obtain prior authorization for listed ENT procedures

Ordering physicians are responsible for obtaining prior authorization from TurningPoint for the listed ENT procedures; failure to obtain authorization may result in non-payment of claims.

Note: Claims may not be paid if authorization is not obtained prior to the service.

Billing Rule

Verify authorization prior to service

Providers should verify that necessary authorization has been obtained before rendering services to avoid claim denial or non-payment.

Documentation Required

Engage in peer-to-peer when requested

Be prepared to engage in specialized peer-to-peer discussions with a TurningPoint physician for authorization requests requiring additional clinical discussion.

TurningPoint physicians may conduct peer-to-peer reviews.