Blue Cross NC Expands Agreement with OrthoNet Effective January 1, 2017

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) expanded our agreement with OrthoNet LLC, to begin prior plan approval (PPA) review for major joint and lower extremities services. This agreement is effective January 1, 2017, for our Blue Medicare HMO^SM and Blue Medicare PPO^SM members.

Blue Cross NC currently uses OrthoNet to provide a uniform, outcome-based set of criteria for the provision of spine surgery and pain management services. And in 2017, OrthoNet will apply this same care management model to major joint and lower extremities services. This approach:

• Integrates the needs of providers, members, and Blue Cross NC
• Ensures the delivery of high-quality, cost-effective care
• Reduces health care costs

Key Points           

• We have delegated the pre-certification process for certain major joint and lower extremities procedures to OrthoNet for our Medicare Advantage members. As such, OrthoNet will be responsible for the prior authorization process and related clinical determinations.
• Providers have access to a complete list of procedure codes requiring prior authorization.
• Primary care provider referrals are not required.
• Claims submitted for services without prior authorization will be subject to denials of service, based on providers’ contracts and members’ Evidence of Coverage. Additionally, services provided without prior authorization may be subject to retrospective medical necessity review.
• Authorizations from OrthoNet are not guarantees of coverage for Blue Cross NC Medicare Advantage members.
• This program does not eliminate any current providers from the Blue Cross NC network.

These frequently asked questions will help answer any questions you may have. We will provide additional information about OrthoNet’s services for our Medicare Advantage members in the coming weeks.

OrthoNet Major Joint and Lower Extremities Code List.pdf