Policies

Martins Point HealthCare (MPHC) follows CMS and Tricare guidelines for the majority of coverage and reimbursement determinations. However there are situations in which MPHC may deviate from these guidelines. As a managed care organization MPHC has developed additional policies that contracted providers are expect to understand and adhere too. If you have questions about a specific policy, please contact provider inquiry at 1-888-732-7364.

Benefit Policy: The purpose of benefit policy is to assure that services are interpreted properly, and the system is configured accurately against the member handbook, the evidence of coverage documents, regulatory requirements, and standard practices (cost share, diagnosis). 

Medical Policy: The purpose of our medical policy is to assure medical necessity criteria is met for a service benefit. Criteria is determined using government program standards along with evidence based clinical resources.

Payment Policy: The purpose of payment policy is to assure that services are reimbursed properly according to contractual, regulatory, internal policy, and industry standards.

Medicare Parts A & B: National Government Services, Inc.
Medical Policy Center

Durable Medical Equipment (DME): NHIC, Corp.
www.medicarenhic.com/dme/mrlcdcurrent.aspx

For more information about Medicare coding and billing criteria, please visit https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/

Tricare Manuals:
https://manuals.health.mil/pages/Search.aspx

Centers for Medicare and Medicaid Manuals:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html