We’re sharing a couple of updates on post-claim appeals for medical necessity for cases managed by TurningPoint.
Exception to the new post-claim appeal limitations for cardiac cases
Effective June 2, we no longer accept appeals for medical necessity review after a claim has been submitted when there’s a denied authorization on file for the following case types:
Outpatient, home health, DME
Elective inpatient
Behavioral health
We ask that, in these cases, providers with a denied authorization submit their medical necessity appeal before performing the service.
Exception: we will still accept post-claim appeals for medical necessity review for cardiac cases managed by TurningPoint.
Determination letters will be available in TurningPoint's portal
Effective July 1, post-claim medical necessity appeal determination letters for procedures managed by TurningPoint for all lines of business are available through TurningPoint’s authorizations portal.
You’ll continue to submit appeals through prism. The only change is that a copy of the determination letter will be available in TurningPoint’s portal rather than in GuidingCare, which is where was located previously.
Reminder: TurningPoint PSCR is different than a post-claim appeal
As a reminder, TurningPoint offers a post-service change request (PSCR) process. This allows you to request a code change to a previously approved authorization if a change was made to the surgical plan during the procedure.
A PSCR request is not an appeal. All PSCRs should be submitted directly to TurningPoint before a claim is submitted, to avoid potential claim denials and subsequent appeals.