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Offering the only 5 star plans in northern new england

Martin’s Point 2019 Generations Advantage Are ONLY Plans in Maine and New Hampshire to Earn 5-Star Medicare Rating

We are proud to announce our 2019 Generations Advantage HMO contract is one of only 14 Medicare Advantage contracts nationwide to earn Medicare’s highest Overall Plan Rating—5 out of 5 Stars!  And it is the only one to earn this distinction in Maine and New Hampshire! The Centers for Medicare and Medicaid Services (CMS) publish their Star Ratings each year to help seniors compare the quality of Medicare Advantage health plans. Overall ratings are based on nearly 50 measures across categories including customer service, member experience, management of chronic conditions, how the plan helps members stay healthy, prescription drug services, and more. Our 5-Star plans are Maine’s most popular Medicare Advantage plans serving over 43,000 members. They are open for enrollment all year long throughout Maine and most counties in New Hampshire.


Update Your Info Online with Provider DataPoint

The Centers for Medicare and Medicaid Services (CMS) now requires us to contact our network providers on a regular basis to confirm that our directory information is up to date. We kindly request that you give best effort to provide us with thirty (30) days advance notice of any changes to your provider/practice information. Also, watch for reminders in future editions of The Point to notify us of any changes to your provider/practice information.
Provider DataPoint is our web-based provider data management tool that helps us maintain accurate provider directories and perform timely and efficient claim processing. Using this tool is an easy way to keep all your practice/provider information up to date and accurate. 
PLEASE NOTE: We no longer accept updates, changes, and credentialing applications via email or fax. Please also note that radiologists, anesthesiologists, and midlevel providers (NP, PA) who do not practice as PCPs do not require credentialing. 
Please use Provider DataPoint to: 

  • Change your practice information, including name, phone/fax, address, billing information, NPI, etc. 
  • Add or delete a location to your already contracted practice/group 
  • Change provider information, including name, specialty, panel status, add a language, etc. 
  • Add a provider who requires credentialing to your practice. 
  • Terminate a provider from your practice/group 
  • Check the status of a previously submitted data change request

To access Provider DataPoint, go to:
If you have questions, see the instructions on our website or speak to your Provider Representative.


HEDIS Record Review is Coming Soon

HEDIS medical record review season is around the corner—January through early May 2019. Martin’s Point will fax record requests early in January. We ask for your support in responding to our requests as quickly as possible to allow for timely audit by our reviewers. The request will include our phone number and an email address for you to use for questions as well as our secure fax number and physical mailing address to expedite delivery of your records to Martin’s Point. Thank you, in advance, for your assistance and for the excellent care you provide to our health plan members.


2019 CMS Opioid Requirements

As required by the Comprehensive Addiction and Recovery Act (CARA), CMS has enacted opioid requirements for all Medicare plans that include Part D benefits. These limits/requirements will be effective January 1, 2019:

  • Opioid-naïve members: All prescriptions for acute pain shall be limited to no more than a 7-day supply. Prescriptions for acute pain should be for immediate-release opioids, not extended-release opioids. Opioid-naïve patients are those patients who have not had at least one day of opioid use in the last 90 days.
  • Maximum Morphine Milligram Equivalents (MME): CMS is following the CDC-recommended guideline of a maximum of 90 MME/day. Opioid prescriptions that are greater than 90 MME will require a review by the dispensing pharmacist with prescribers for Generations Advantage members. Once reviewed and determined appropriate, the dispensing pharmacist can place an override and dispense the opioid. Opioid prescriptions greater than 200 MME/day will require a Prior Authorization for Generations Advantage members. The CDC guideline fact sheet is available here: 
  • Exclusions: Patients who are residents of Long Term Care (LTC) facilities, in hospice or palliative care, or being treated for active, cancer-related pain will be excluded from these limits.
  • Medication-Assisted Treatment (MAT): CMS encourages eliminating barriers to member access to receiving opioid-related MAT.


TRICARE® Pharmacy Requirements for Maintenance Medications 

Did you know that, under Department of Defense TRICARE policy, US Family Health Plan members must use the Martin's Point Mail-Order Pharmacy or one of the Martin's Point Health Care Center Pharmacies (in Portland, ME and Portsmouth, NH) for their maintenance medications?
Luckily for members, that means cost savings (lower copays) and convenience.
Exceptions—Members may fill the following kinds of prescriptions at an in-network retail pharmacy:
  • New prescriptions 
  • Medications for urgent/acute needs (such as antibiotics)
  • Medications only taken when needed (PRN)
  • Dosage changes (some maintenance medications require dosage adjustments to find the right dose)
  • Class II prescriptions such as narcotics and Attention Deficit Disorder (ADD) medications

First fills of new maintenance medications can be filled at any pharmacy. For refills, please send a 90-day-supply script to a Martin's Point Pharmacy. Some restrictions apply. Some liquids, refrigerated items, and controlled substances cannot be mailed.


Coming Soon in 2018: New Provider Portal!

A Better Provider Portal Experience Coming Soon!

Do you already use the Martin’s Point Provider Portal? Then you know the benefits of online self-service—like being able to access needed forms and information on your own time, or change users and reset passwords, without having to call for assistance. 
Our new Provider Portal, coming soon in 2018, promises all this functionality, plus added features and a redesign that makes your work easier and more efficient.
NEW features include:
  • Streamlined system allows a user to access multiple providers/groups with a single user name
  • Ability to review claims remittance details
  • Real-time eligibility checking 
  • A central, searchable repository where all forms, policies, and documents are organized by category

Functionality Overview:



Annual Updates

Martin’s Point strives to ensure our members and our network providers are well informed about our health plans. We update our website periodically to provide useful information and tools.

Health Management

RNs, social workers, and pharmacists are available to partner with you to provide case management, disease management, health coaching, and medication-adherence support for your patients.
For more information Resources/Health-Management

To refer a member or for more information: 1-866-800-8833.

Clinical Guidelines

Clinical guidelines offer an evidence-based framework to assist providers and patients in the diagnosis and treatment of common diseases and conditions. Martin’s Point selects clinical guidelines issued by nationally recognized expert bodies.
For more information
For more information or a copy of the guidelines: 1-866-800-8833.

Utilization Management (UM) 

The UM team is committed to ensuring that patients receive appropriate care for their medical condition(s). UM decisions are based on criteria designed to meet the needs of patients based on their individual medical condition(s). UM decisions are based only on appropriateness of care and existence of coverage. All medical reviewers follow these criteria and there are no incentives (financial or other) to deny care.
For more information
UM criteria is available through our Health Management Department at 1-888-339-7982, Monday through Friday, 8 am–4:30 pm. Messages left after business hours will be responded to on the next business day. Our fax number for UM related issues is 207-828-7865.
Information on preauthorization can be found at

Member Rights and Responsibilities

Martin’s Point ensures all new and existing members receive communication regarding their rights and responsibilities.
For more information
Martin’s Point US Family Health Plan: We notify members of their rights and responsibilities via the US Family Health Plan Member Handbook, our emailed member newsletter, and an annual member mailing directing them to information on our website:
Martin’s Point Generations Advantage: We notify members of their rights and responsibilities in their annual Evidence of Coverage document and on our website:

Martin’s Point Quality Management Program (QMP)

The QMP provides the structure and formal processes to systematically monitor and evaluate the quality, appropriateness, efficiency, safety, and effectiveness of care and service.
Martin’s Point adopted the Institute for Healthcare Improvement’s (IHI) Triple Aim as our quality framework. The Triple Aim is an approach to optimize health system performance by simultaneously pursuing three dimensions:

  • Improving the patient experience of care
  • Improving the health of populations
  • Reducing the per-capita cost of health care

For more information
For a summary report on progress in meeting quality-improvement goals: 1-888-732-7364 or email at: [email protected]


The Martin’s Point Credentialing team (or its designated qualified agent) reviews facility and provider documentation to determine eligibility for participation in our health plan network. Martin’s Point recognizes the provider’s right to:

  • Review information submitted in support of their credentialing/recredentialing application (to the extent permitted by law)
  • Correct erroneous information Receive the status of their credentialing/recredentialing application upon request (via phone or mail)
  • Review their credentialing file by scheduling an appointment (via phone or mail)

For more information
Providers may contact us at:
Email: [email protected]
Phone: 207-253-6930 or 1-800-348-9804
Fax: 207-828-7870
Martin’s Point Health Care
ATTN: Credentialing Department 
PO Box 9746
Portland, ME 04104

Behavioral Health

Martin’s Point has partnered with MaineHealth and its Behavioral Health Care Program (BHCP) to provide integrated behavioral health services to our members.
For more information
Behavioral health providers and facilities may be found at:
BHCP is available to members 24 hours a day, seven days a week, for triage and referral toll-free:
US Family Health Plan Members: 1-888-812-7335
Generations Advantage Members: 1-800-708-4532


Our health plan formularies are frequently updated to keep pace with new clinical data and evolving drug classes. Our goal is to maintain a broad, clinically sound formulary and to help drive generic utilization to reduce pharmacy costs for your patients. We distribute revised formularies to our members on an annual basis and will inform members and providers when changes are made.
For more information
Information on our pharmacy management procedures including drug preauthorization, step-therapy and quantity requirements, and links to formularies can be found at
Information on therapeutic interchange and step-therapy protocols for the US Family Health Plan are available at
For preauthorizations or other questions related to pharmacy benefits, please call us at 1-888-732-7364.


Accessibility Standards Reminder

Please review the current Service Standards per the Martin’s Point Provider Manual outlined below. Provider agreements support these patient service standards, which are consistent with TRICARE®, CMS, commercial, and state regulations. 
Accessibility Standards

Patients Seeking Imaging for Uncomplicated Low Back Pain?

Remember to Discuss Potential Risks

Most providers are aware that imaging studies are overused when evaluating uncomplicated low back pain. However, many still order the tests because patients request them. Ironically, rather than having their minds set at ease, patients with imaging results showing degenerative changes—commonly found in asymptomatic individuals—frequently misinterpret the results, leading to fear, avoidance of activity, and low expectations of recovery. Even worse, misinterpretation of results by clinicians may result in unhelpful advice, needless downstream testing, or invasive intervention.
We encourage clinicians to take the time to discuss the risks and benefits of imaging with their patients. A short conversation about the risks of radiation, expected time frames for recovery, and recommended treatments can go a long way in helping inform shared treatment decisions.
Highlights from the American College of Physicians clinical practice guideline of noninvasive treatments for acute, subacute, and chronic low back pain state that:

  • Acute back pain is defined as lasting fewer than four weeks. Subacute back pain lasts four to 12 weeks.
  • Most patients with acute back pain have self-limited episodes that resolve on their own. 
  • Symptoms usually improve within the first month regardless of treatment
  • Clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence).
  • If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

Erika D. Sears, Erika, Tanner J. Caverly, Jeffrey T. Kullgren, Angela Fagerlin, Brian Zikmund-Fisher, Brian, Katherine Prenovost, Eve A. Kerr. “Less is more: clinicians’ perceptions of barriers to avoiding inappropriate imaging for lowback pain—knowing is not enough” JAMA Internal Medicine, 176. no. 12 (2016) 1866-1867. Accessed August 07, 2017. doi:10.1001/jamainternmed.2016.6364
Waleed Brinjikji, Patrick H. Luetmer, Bryan Comstock, Brian W. Bresnahan, L.E. Chen, Richard A. Deyo, … Jeffrey G. Jarvik, (2015). “Systematic literature review of imaging features of spinal degeneration in asymptomatic populations.” AJNR. American Journal of Neuroradiology, 36, no. 4 (2015): 811–816. Accessed August 7, 2017. doi: 10.3174/ajnr.A4173
Darlow, Ben, Bruce B. Forster, Kieran O’Sullivan, and Peter O’Sullivan. "It is time to stop causing harm with inappropriate imaging for low back pain." British Journal of Sports Medicine 51, no. 5 (2016): 414-15. Accessed August 7, 2017. doi:10.1136/bjsports-2016-096741.
Qaseem, Amir, Timothy J. Wilt, Robert M. McLean, and Mary Ann Forciea. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of Internal Medicine 166, no. 7 (2017): 514-30. Accessed August 7, 2017. doi:10.7326/p17-9032.


2019 Plan Benefit Updates Available January 1

Please remember to confirm member benefits at the start of each plan year, as benefits can change annually. Updated 2019 Plan Year benefits for Martin’s Point Generations Advantage and the Martin’s Point US Family Health Plan will be available through the Provider Portal on 1/1/2019.
Generations Advantage: Multiple benefit changes have occurred and we have added a new plan option called the Generations Advantage Flex (RPPO) plan. 
Additional covered services may include (see member’s individual plan for potential coverage):

Hearing Aids (through Amplifon)
Nutrition & Dietary Services
Weight Management Programs
Remote Access Technology
Smoking Cessation
OTC Benefits (through CVS Caremark)
Personal Emergency Response System
Fall Prevention
Bathroom Safety
Vision Services


Formulary Change for 2019: Benzodiazepines 

In response to the Comprehensive Addiction and Recovery Act of 2016 (CARA), CMS is implementing new CARA regulations to strengthen their efforts against the opioid epidemic. Per the CMS 2019 Final Call Letter, CMS will now designate benzodiazepines as frequently abused drugs. 
For Generations Advantage Prime (HMO-POS), Select (PPO), Focus DC (HMO SNP), and Value Plus (HMO) members, all benzodiazepines except lorazepam, will be designated as Tier 2 medications. Lorazepam will stay as a Tier 1 medication through 2019 to help transition our members. 
For members of the new Generations Advantage FLEX (RPPO), ALL benzodiazepines will be designated as Tier 2. 
Please be sure to work with your patients to determine which medication is right for them throughout this transition and beyond.


Receive Claims Payments Faster: Sign Up for Our EFT Option

Are you currently receiving paper checks from us for claim payments? Did you know you can get your claims payments faster by using our Electronic Funds Transfer (EFT) option? By authorizing us to directly deposit your payments into your bank account via EFT, the delay of processing and mailing a paper check is eliminated.
To receive your claim payments via EFT, please use the Direct Deposit Authorization Form found on our website at Please include your bank routing and account number on the form to expedite the EFT set-up process. 
As always, we encourage you to reach out to our Provider Inquiry team at 1-888-732-7364 with any questions. Current information may be found online at