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.

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. Criteria is determined using government program standards and evidence-based clinical resources.

For more information on utilization management decisions, visit out 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.