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¿ERES UN MIEMBRO NUEVO? REALIZA TU PRIMER PAGO PARA ASEGURAR LA COBERTURA.

¿ERES UN MIEMBRO NUEVO? REALIZA TU PRIMER PAGO PARA ASEGURAR LA COBERTURA.

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Sunflower Partnering with NIA for Musculoskeletal (MSK) Management

Fecha: 29/02/24

Sunflower Health Plan is pleased to announce that beginning April 1, 2024, we are expanding our partnership with National Imaging Associates, Inc. (NIA), to provide utilization management services for the Musculoskeletal (MSK) Management program (orthopedic surgery and pain management).

This program includes prior authorization for non-emergent MSK procedures, including outpatient interventional spine pain management services (IPM); inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries for Sunflower’s KanCare, Ambetter from Sunflower Health Plan, Wellcare Complete and Wellcare by Allwell members. This decision 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 this agreement, Sunflower KanCare, Wellcare by Allwell and Ambetter from Sunflower Health Plan will terminate the current MSK program with TurningPoint Healthcare as of April 1, 2024.

Under terms of the agreement between Sunflower Health Plan and NIA, Sunflower will oversee the MSK program and continue to be responsible for claims adjudication and medical policies. NIA will manage non-emergent outpatient interventional spine pain management services, and inpatient and outpatient MSK surgeries through the existing contractual relationships with Sunflower for all lines of business.

Planned for an April 1, 2024, implementation, this correspondence serves as notice of changes to the program under your Participating Sunflower Health Plan Provider Agreement.

Providers may begin contacting NIA on April 1, 2024, to seek prior authorization for procedures scheduled on or after April 1, 2024.

The following outlines the specific procedures requiring prior authorization.

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

  • Spinal Epidural Injections
  • Paravertebral Facet Joint Injections or Blocks
  • Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis)
  • Sacroiliac Joint Injections  
  • Sympathetic Nerve Blocks
  • 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/pincer & labral repair)
    • Hip Surgery – Other (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
    • Knee Surgery – Other (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
    • Shoulder Surgery – Other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)
  • Lumbar
    • Lumbar Microdiscectomy
    • Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy)
    • Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single & Multiple Levels
    • Sacroiliac Joint Fusion
  • Cervical
    • Cervical Anterior Decompression with Fusion – Single & Multiple Levels
    • Cervical Posterior Decompression with Fusion – Single & 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 interventional spine pain management procedures and MSK surgeries outlined above.
  • NIA does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those procedures listed above.
  • The ordering physician must obtain prior authorization with NIA prior to performing the surgery/procedure.
  • Facility admissions do not require a separate prior authorization. However, the facility should ensure that an NIA prior authorization has been obtained prior to scheduling the surgery/procedure.

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

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

We will provide additional information as we get closer to the implementation date. Should you have questions at this time, please contact Provider Relations at: