Musculoskeletal (MSK) Management Program prior authorization
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Governs prior authorization requirements and management of non-emergent outpatient interventional spine pain management (IPM) and specified inpatient/outpatient MSK surgeries for Meridian Health Plan of Michigan members; affects participating providers across Meridian Michigan lines of business.
Meridian transitioned MSK program management from TurningPoint Healthcare to Evolent effective April 1, 2024, with TurningPoint contract terminating March 31, 2024.
Prior authorization requirement expanded to include spinal cord stimulators and inpatient/outpatient hip, knee, shoulder, lumbar, and cervical spine surgeries under Evolent management.
Coverage Criteria
Prior Authorization Criteria
Covered when prior authorized by Evolent for Meridian Michigan members
Providers must obtain prior authorization from Evolent prior to performing the procedure.
Providers may begin contacting Evolent on April 1, 2024 to seek prior authorization for procedures scheduled on or after April 1, 2024.
Ambetter from Meridian is excluded from the IPM program.
Evolent will not manage prior authorization for emergency MSK surgery cases admitted through the emergency room or for MSK surgery procedures outside the specified procedures listed in this program. Providers should follow existing prior authorization processes for MSK surgeries not included in Evolent’s scope and for emergency admissions.
Ambetter from Meridian is excluded from the Interventional Spine Pain Management (IPM) prior authorization program managed by Evolent.
Coding and CPT Lists
| See RadMD CPT list | Complete list of CPT codes included in this program is available at RadMD |
Provider Actions and Requirements
Evolent prior authorization required
Providers must obtain prior authorization from Evolent for non-emergent outpatient interventional spine pain management (IPM) services and for specified inpatient and outpatient MSK surgeries (including spinal cord stimulators; hip, knee, shoulder, lumbar, and cervical spine surgeries) for procedures scheduled on or after April 1, 2024.
- Providers may begin contacting Evolent on April 1, 2024 to seek prior authorization for procedures scheduled on or after April 1, 2024.
- Ambetter from Meridian is excluded from the IPM program.
Ordering physician responsibility
It is the responsibility of the ordering physician to obtain prior authorization from Evolent for all IPM procedures and MSK surgeries managed by Evolent; ensure authorizations are secured before scheduling elective procedures.
- Contact Evolent beginning April 1, 2024 for procedures scheduled on or after that date.
- MSK surgeries outside the listed procedures and emergency admissions through the ER are not managed by Evolent.
Authorization documentation and facility admission guidance
Obtain and document an Evolent prior authorization prior to performing the surgery/procedure; facility admissions do not require a separate prior authorization but the facility must ensure an Evolent prior authorization exists before scheduling.
- Verify and record the Evolent authorization in the patient record prior to the procedure.
- Facilities should confirm authorization when scheduling elective admissions.
Denial risk if prior authorization not obtained
Failure of the ordering physician to obtain prior authorization from Evolent for IPM procedures and MSK surgeries managed by Evolent may result in denial of coverage.
- Emergency MSK surgeries admitted through the emergency room are excluded from Evolent management and this denial risk.
- Procedures outside the specified list follow existing prior authorization rules for each line of business.
Background
This notice describes an administrative change in prior authorization management for musculoskeletal (MSK) care. Meridian has transitioned MSK program management from TurningPoint Healthcare to Evolent effective April 1, 2024, with the TurningPoint contract terminating March 31, 2024. Under the new arrangement, Evolent will manage non-emergent outpatient Interventional Spine Pain Management (IPM) services and specified inpatient and outpatient MSK surgeries (including spinal cord stimulators; hip, knee, shoulder, lumbar, and cervical spine surgeries). Providers may begin contacting Evolent on April 1, 2024 to obtain prior authorization for procedures scheduled on or after that date.
Definitions
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