Ambetter of Illinois Cardiac Surgical Quality and Safety Management Program in Partnership with TurningPoint

Date: 07/01/25

Ambetter of Illinois (Ambetter Health) is pleased to announce the launch of a new and innovative Cardiac Surgical Quality and Safety Management Program. The program is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for Ambetter Health members undergoing cardiac surgical procedures.

PROGRAM HIGHLIGHTS INCLUDE:

• Administrative Tools to support an efficient, user-friendly request process for obtaining medical necessity prior authorizations for procedures which require precertification. Easy and efficient post-procedural documentation submission which will be shared with Ambetter 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 current condition.
• Clinical Support Tools to assist in the tracking and monitoring of patient outcomes and education about patient risks and preventive measures to better coordinate care for the member and reduce infection rates and complications due to patient comorbidities.
• Reporting and Analytics that gives 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 Ambetter of Illinois when a member has received or needs a revision surgery due to a Class I or II FDA device recall. 

This correspondence serves as notice under your Participating Ambetter of Illinois Provider Agreement of these program changes, effective September 1, 2025. Physicians can begin submitting prior authorization requests to TurningPoint beginning August 18, 2025, for dates of service on or after September 1, 2025. 

While it is the responsibility of the rendering physician to obtain prior authorization, facility providers are encouraged to contact TurningPoint to verify the prior authorization is completed for Ambetter Health members prior to admission.

Prior Authorization for medical necessity and appropriate 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 SURGERIES & PROCEDURES

Including all associated partial, total, and revision surgeries

• Coronary Angioplasty/Stenting
• Internal Cardiac Monitoring
• Implantable Cardioverter Defibrillator
• Leadless Pacemaker
• ICD Revision or Removal
• Left Atrial Appendage (LAA) Occluders
• Non-Coronary Angioplasty/Stenting
• Pacemaker
• Pacemaker Revision or Removal
• Peripheral Revascularization
• Percutaneous Transcatheter Closure
• WCD - Wearable Cardiac Defibrillator
• Cardiac Ablation
• Coronary Artery Bypass Grafting

TURNINGPOINT’S UTILIZATION MANAGEMENT & PRECERTIFICATION CONTACT INFORMATION:

• Web Portal Intake: myturningpoint-healthcare.com
• Telephonic Intake: 872-221-6010 | 855-415-7481
• Facsimile Intake: 855-868-2055

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 claimsAccess digital copies of clinical policies by contacting TurningPoint at (855) 415-7481

Training:

Informational webinars are available. Please register at: https://us06web.zoom.us/meeting/register/h6N2nYgwSbONgArIbK3IqQ 

We will provide additional information and training opportunities as we get closer to the effective date of the program. For questions, please contact Ambetter Health Provider Services at 855-745-5507.

Below are listed the CPT and HCPCS codes impacted by this program:

CPT Codes:

0075T, 0076T, 0483T, 0484T, 0571T, 0572T, 0573T, 0574T, 0580T, 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0823T, 0824T, 0825T,  0861T, 0862T, 0863T, 33202, 33203, 33206, 33207, 33208, 33210, 33211, 33212, 33213, 33214, 33221, 33224, 33225, 33227, 33228, 33229, 33230, 33231, 33233, 33236, 33237, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33274, 33275, 33285, 33286, 33340, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33405, 33406, 33410, 33411, 33412, 33413, 33418, 33419, 33430, 33440, 33465, 33475, 33477, 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33530, 33533, 33534, 33535, 33536, 33572, 35302, 35303, 35304, 35305, 35371, 35372, 35556, 35558, 35566, 35571, 35583, 35585, 35587, 35656, 35661, 35666, 35671, 35700, 35881, 35883, 35884, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235, 37236, 37237, 37238, 37239, 37246, 37247, 37248, 37249, 4110F, 92928, 92929, 92933, 92934, 92937, 92938, 92943, 92944, 93745, 92920, 92921, 92924, 92925, 0913T, 0914T, 93580, 93653, 93654, 93656

HCPCS Codes:

C1721, C1722, C1764, C1777, C1779, C1785, C1786, C1874, C1875, C1876, C1877, C1880, C1882, C1895, C1896, C1898, C1899, C1900, C2617, C2619, C2620, C2621, C2623, C2625, C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, C9608, E0616, G0448, K0606, S2205, S2206, S2207, S2208, S2209, C1605, C7564, C9610