Utilization Management

Authorizations

Timely Notifications of Urgent Admissions: Admitting providers please be sure to notify the Martin’s Point Health Management department of all urgent hospital admissions within 24 hours of admission (or next business day, if after hours or on weekends). Failure to notify in a timely manner may result in denial of payment for services provided.

For select services and procedures, providers are required to request authorization from Martin's Point. Authorization, also known as precertification, is the process of reviewing certain medical services to ensure medical necessity and appropriateness of care prior to services being rendered. The review also includes a determination of whether the service being requested is a covered benefit under the members benefit plan. A list of codes that require authorization by our health plans is available here. Whenever possible, authorization requests should be submitted at least two weeks prior to the date of service or facility admission. Authorization is not required for emergency care. However, when one of our members is admitted to a medical facility, providers should notify Martin's Point within 24 hours by calling 1-888-339-7982.

Authorizations are subject to a member's eligibility, enrollment status and covered benefits. If the authorization review process identifies care that is not medically necessary, services will not be covered. Determination letters are sent to the member, specialty physician, and facility (if applicable). Denial notifications include the reason for the denial, reference to the criteria or benefit provision used in the decision, a copy of the criteria or benefit provision used in the decision, and instructions for requesting an appeal. Martin's Point uses qualified, licensed, health professionals to assess the clinical information used to support authorization decisions. Decision-making is based only on appropriateness of care/medical necessity and existence of coverage. Denials based on medical necessity are made only by physicians. We do not specifically reward practitioners or other individuals for issuing denials of coverage, nor do we provide financial incentives to encourage decisions that result in underutilization. Providers, along with the member, make the decision whether to proceed with a service or procedure.

Please do not resubmit authorization requests unless directed to do so by Martin's Point. Casual inquiries about benefits, or the circumstances under which benefits might be paid, are not considered requests for authorization.

For authorization of mental health/substance abuse services, please call the Behavioral Health Care Program at 1-888-812-7335. For drug authorizations, visit our Pharmacy Forms and Documents page. For outpatient therapy (PT, OT, ST, SLP), please use our Outpatient Therapy Prior Authorization Request Form.

Behavioral Health

Martin’s Point has partnered with the Maine Medical Center Physician-Hospital Organization and its Behavioral HealthCare Program (BHCP) to provide integrated behavioral health services to our members. Our goal is to connect patients with behavioral health resources that can help make the important connections between their emotional and physical well-being. The BHCP is available to members for triage and referral 24 hours a day, seven days a week, through a toll-free telephone line
US Family Health Plan: 1-888-812-7335 
Generations Advantage: 1-800-708-4532

The BHCP is committed to: 
• A case management focus 
• Utilization of criteria for review in a consistent manner 
• Clinical multidisciplinary approach to care management 
• Physician decisions made by local practitioners 
• Identification and support of a selected network of providers/vendors who demonstrate a shared commitment to high-quality, accessible care that will lead to the highest member satisfaction 

When a Martin’s Point health plan member inquires about coverage for mental health or substance abuse services, the Member Services team answers questions and refers him or her to the BHCP for authorization of services. The BHCP also documents concerns, complaints, and appeals. 

BHCP maintains its own network of contracted facilities and behavioral health specialists, including hospitals, psychiatrists, clinical psychologists, clinical social workers, licensed pastoral care counselors, marriage and family therapy counselors, clinical professional counselors, and other licensed clinicians. These providers and facilities are listed in the Provider Directories on Martin’s Point health plan sites. Benefit coverage requires prior authorization for all services. Clinical criteria are used to determine medical necessity of behavioral health services. 

It is the policy of the BHCP to address the individual needs of members. To that end, the BHCP provides alternative clinical guidance to decision makers. In some instances, additional factors (e.g. age, comorbidities, complications, treatment progress, etc.) affect a clinical situation and the criteria are overridden to tailor the service to the member. This may occur with specific situations such as psychosocial situations, home environment, or lack of available services. 

BHCP is committed to keeping member information confidential. All persons employed by BHCP are responsible and accountable for safeguarding this information in a consistent, thoughtful, and effective manner in accordance with state and federal law and the National Committee for Quality Assurance (NCQA). The BHCP follows all Health Insurance Portability & Accountability Act (HIPAA) regulations and requirements. For more information about Martin’s Point behavioral health services, providers may call 1-800-538-9698.

Prior Authorization

Prior Authorization may be requested by the member's Primary Care Provider (PCP) or by the servicing provider using our online Authorization Request form. If the servicing provider is not part of the Martin's Point network, submit this form with a letter of medical necessity (including clinical documentation) explaining why the service(s) can only be provided by this specialist. To determine if a provider is part of our network, please refer to our Provider Directory. Our prior authorization categories are as follows:

Prospective Non-Urgent: Prior Authorization requests based on a future need for medical care or a service (e.g., consultation or surgery planned for a later date). Most prior authorization requests fall in this category. Determinations are generally made within 14 calendar days from receipt of request.

Prospective Urgent: Prior Authorization requests for immediate services or procedures which could not have been anticipated prior to the submission date. Prospective Urgent determinations are made as soon as possible based on the clinical situation, and, in no event, later than 72 hours from receipt of request. (Note: Prior Authorization requests for services that were ordered by a provider more than two weeks prior to receipt of the request by Martin's Point will not be processed as Prospective Urgent. Such requests will be reviewed as Prospective Non-Urgent.)

Urgent/Emergent: Prior Authorization requests in circumstances under which a prudent layperson would consider that waiting for a Prospective Urgent care determination could result in seriously jeopardizing the life or health of the member, or the member's ability to regain maximum function. Or, it is the servicing practitioner's opinion that waiting for a Prospective Urgent care determination would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. For urgent/emergent services occurring after normal business hours, the Martin's Point Health Management Department must be contacted by the rendering provider or facility the next business day. Please call 1-888-339-7982 with the member's name, date of birth, the facility name and contact information, the date of admission, the attending physician, and the admitting diagnosis.

Retrospective Authorization

Retrospective authorization requests are for services that have already been rendered (or will be imminently) for which prior authorization was not obtained.

US Family Health Plan: We will review retrospective authorization requests for all qualified care, before or after claim submission. Both participating and non-participating providers may submit requests using our online Authorization Request Form. Determinations are made within 30 calendar days of receipt of request.

Generations Advantage:

As indicated in the Martin’s Point Provider Manual, Martin’s Point will review payment disputes due to the failure to obtain prior authorization for beneficiaries only under the circumstances outlined in the Failure to Obtain Authorization Form.
  • Documentation is required. "Not Enough Time" situations do not include when the provider renders a service that is considered experimental or investigational, and/or is not a covered benefit.

If your situation meets one of these criteria, please submit your retrospective authorization request with documentation that supports the criteria outlined above. We will assess if the criteria was met, if so we review coverage and if it requires medical necessity. We will first assess the criteria for coverage and then for medical necessity.

  • Participating providers seeking retrospective authorization for a Generations Advantage member must file a claim for that service, wait for claim denial, and then submit an Authorization Dispute Form.
  • Non-participating providers seeking retrospective authorization for a Generations Advantage member must file a claim for that service, wait for claim denial and then initiate the claim appeal process on behalf of the member. We cannot begin the appeal process without a Medicare Appointment of Representative Form. Determinations are made within 60 calendar days of receipt of request.

Referrals

A referral is not the same as an authorization request or approval. A referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. All referrals should be documented in the member's medical chart or electronic health record. A referral does not imply or guarantee payment.

US Family Health Plan Referrals

The US Family Health Plan is built upon the relationship between the member and the PCP. The PCP is responsible for coordinating all patient care and making initial referrals for specialty care. Specialists, in turn, are responsible for communicating their findings, plans of care, and progress back to the PCP. Except for a few instances when self-referral is allowed, US Family Health Plan members must receive a referral from their PCP before seeing any other provider or specialist. Please view the Member Handbook for complete details. Whenever possible, please refer US Family Health Plan Members to a participating provider or facility. To find out if a provider or facility participates in our network, check our online directory or call 1-888-732-7364.

Generations Advantage Plan Referrals

Generations Advantage HMO plan members are required to select a PCP and to obtain referrals in advance from their PCP for most covered services. Self-referral is allowed in some situations. Referral requirements vary by plan. Please view the individual plan documents for complete details. Whenever possible, please refer Generations Advantage members to a participating provider or facility. To find out if a provider or facility participates in our network, check our online directory or call 1-888-732-7364.

For Generations Advantage only - eviCore healthcare (eviCore)

eviCore healthcare (eviCore) is an independent, specialty medical benefits-management company that provides utilization management services for Martin’s Point Health Care.

eviCore will manage authorizations for the following radiology and cardiology services for our Generations Advantage members.

  • Advanced Imaging (CT, MR, PET)
  • Myocardial Perfusion Imaging (Nuclear Stress)
  • Echo
  • Echo Stress
  • Cardiac Imaging (CT, MR, PET)
  • Ultrasound (non-OB)
  • Nuclear Medicine

The quickest, most efficient way to obtain prior authorization for any of these services is through eviCore’s 24/7 self-service web portal at www.eviCore.com/healthplan/Martins_Point.

Prior authorization can also be obtained via phone at 1-888-693-3211 or fax at 1-888-693-3210. Their call center is available at 1-888-693-3211 from 7 am–8 pm, ET, Monday through Friday.
The following information must be submitted to eviCore in order to receive a medical-necessity determination:

  • Procedure requested
  • Patient, ordering provider, and rendering site information
  • Prior/ongoing treatments and their effects
  • Current clinical condition and recent test results