musculoskeletal procedures authorization

Date: 04/28/23

In keeping with our commitment of promoting continuous quality improvement for services provided to WellCare of New Jersey (WellCare) Medicaid, Medicare, and Ambetter members, WellCare has entered into an agreement with National Imaging Associates Inc. (NIA) to implement a musculoskeletal (MSK) management program. This program includes prior authorization for non-emergent MSK procedures, including outpatient interventional spine pain management services (IPM) specific to spinal cord stimulators; and inpatient and outpatient hip, knee, shoulder, lumbar, and cervical spine surgeries for WellCare Medicaid, Medicare, and Ambetter members. The decision to work with NIA is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

In consideration of the aforementioned agreement, WellCare will terminate its current MSK program and utilization management efforts with TurningPoint as of June 30, 2023.

Under the terms of the agreement between WellCare and NIA, WellCare will oversee the MSK program and continue to be responsible for claims adjudication and medical policies. NIA will manage inpatient and outpatient MSK surgeries through existing contractual relationships with WellCare.

Planned for a July 1, 2023, implementation, this correspondence serves as notice of changes to the program under your Participating Provider Agreement. Providers may begin contacting NIA on July 1, 2023, to seek prior authorization for procedures scheduled on or after July 1, 2023.  Please see the following pages for specific procedures requiring prior authorization.

IPM Component: Prior authorization will be required for the following non-emergent outpatient interventional spine pain management services:

• Spinal Cord Stimulators

MSK Surgeries: Prior authorization will be required for the following non-emergent inpatient and outpatient hip, knee, shoulder, lumbar, and cervical surgeries:

• Hip
  • Revision / conversion hip arthroplasty
  • Total hip arthroplasty / resurfacing
  • Femoroacetabular impingement (FAI) hip surgery (includes CAM / pincher and labral repair)
  • Other hip surgery (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)
• Knee
  • Revision knee arthroplasty
  • Total knee arthroplasty (TKA)
  • Partial-unicompartmental knee arthroplasty (UKA)
  • Knee manipulation under anesthesia (MUA)
  • Knee ligament reconstruction / repair
  • Knee meniscectomy / meniscal repair / meniscal transplant
  • Other knee surgery (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release / patellar realignment, articular cartilage restoration)
• Shoulder
  • Revision shoulder arthroplasty
  • Total / reverse shoulder arthroplasty or resurfacing
  • Partial shoulder arthroplasty / hemiarthroplasty
  • Shoulder rotator cuff repair
  • Shoulder labral repair
  • Frozen shoulder repair / adhesive capsulitis
  • Other shoulder surgery (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)
• Lumbar
  • Lumbar microdiscectomy
  • Lumbar decompression (laminotomy, laminectomy, facetectomy, and foraminotomy)
  • Lumbar spine fusion (arthrodesis) with or without decompression (single and multiple levels)
• Cervical
  • Cervical anterior decompression with fusion (single and multiple levels)
  • Cervical posterior decompression with fusion (single and multiple levels)
  • Cervical posterior decompression (without fusion)
  • Cervical artificial disc replacement
  • Cervical anterior decompression (without fusion)

Key Provisions:

• It is the responsibility of the ordering physician to obtain prior authorization for all MSK surgeries outlined above.
• NIA does not manage prior authorization for emergency MSK surgery cases that are admitted via the emergency room, nor for MSK surgery procedures outside of those procedures listed above.
• Any prior authorization requirements for facility or hospital admission must be obtained separately and only initiated after the surgery / procedure has met NIA’s medical necessity criteria.

Services other than the interventional spine pain management and MSK surgeries outlined above will continue to follow WellCare prior authorization requirements for hospital admissions and elective surgeries.

Providers will be able to request prior authorizations 24 hours a day, seven days a week via the NIA website at RadMD.com. For providers unable to submit authorizations using RadMD, contact our call center at:

• WellCare of New Jersey (Medicaid): 1-866-249-1585
• Wellcare (Medicare): 1-800-424-5388
• Ambetter from WellCare of New Jersey: 1-800-642-7821

We will provide additional information as we get closer to the implementation date. If you have any questions, please contact the WellCare Provider Services Department at 1-888-453-2534.

We appreciate your support and look forward to your help in assuring that WellCare members receive MSK services delivered in a quality, clinically appropriate fashion.