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Claims

A guide to the claims process at Martin's point, including billing and coding criteria.

Below is detailed information about the claims process for health plan members enrolled in Generations Advantage or the US Family Health Plan.

Some of our members are covered by both Martin's Point US Family Health Plan and Medicare plans. Please note that the US Family Health Plan is primary to Medicare (with very few exceptions) and claims should not be submitted to Medicare for services covered by US Family Health Care.

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Claims Requirements Claims Filing Claim Adjustments Corrections & Disputes Electronic Remittance & EFT Coding & Billing Criteria Coordination of Benefits Point-of-Service Hold Harmless Claim Audits & FWA


Claims Requirements

Martin's Point Health Care utilizes HIPAA standard code sets for claims processing. Requirements for US Family Health Plan and Generations Advantage are generally consistent with industry practices. Claims for services rendered must be submitted to Martin's Point Health Care consistent with contractual obligations. Claims may be filed electronically (preferred) or on paper, using a CMS-1500 Form or UB-04 Form, as appropriate.


The following information is required for processing:

All mandatory fields must be complete and accurate. Missing or incomplete information will result in claim returns.

  • Patient's full name: Must be spelled correctly, as it appears on the patient's ID card.
  • Patient's Plan ID number including two-digit suffix: Must be entered as it appears on patient’s ID card.
  • Patient's date of birth and gender: Must be completed for claim processing.
  • Insured's/subscriber's full name: Must be spelled correctly, as it appears on the patient's ID card.
  • Insured's/subscriber's ID number including two-digit suffix: Subscriber ID numbers end in "00" and dependent ID numbers end in, "01,02, 03, etc." according to the number of dependents. Samples of our health plan ID cards are shown below.
  • Insured's/subscriber's date of birth and gender: Must be completed for claim processing.
  • Date of service
  • Place of service
  • Service provider's name and address
  • Service provider's federal tax identification number (TIN)
  • Industry standard diagnosis codes (ICD-10)
  • Industry standard procedure codes (CPT/HCPCS)
  • Charge information and units

Tips for getting your claims processed more quickly

We want to pay your claims as quickly as possible. Please help us do so by filling out your claim forms carefully. Claim form errors can significantly delay processing.

Here are some common CMS-1500 Claim Form errors that we see, and tips on how to avoid these errors and get your claims paid more quickly:

number one icon It is very important for Provider NPI and Billing Provider NPI information to be properly presented.

  • Box 24J – This is the NPI number of the individual provider rendering the service (i.e., the Type 1 NPI of the specific physician rendering the service). Enter the rendering provider NPI number in the field to the immediate right of the letters “NPI.” Not in the blank spaces above or below. 

    • 837: Loop 2310B Segment NM109

  • Box 33A – This is the NPI of the billing entity named in Box 33 (i.e., the Type 2 NPI assigned at a group level to the practice). Type 2 NPI numbers are also known as "organizational" NPI numbers. In most instances, the number in Box 33A should not be the same as the number in Box 24J.

    • 837: Loop 2010AA Segment NM109

number two icon

  • Box 32: Service location information in Box 32 is required and key to efficient claim processing, particularly if your practice delivers services at multiple locations. If left blank, the billing location will be used by default as appropriate to process claims.
    • 837: Loop 2310C Segments NM103, N301, N401, N402 and N403
      • Note: Do not fill out box 32A (Loop 2310C Segment NM109) if NPI matches box 33A (Loop 2010AA Segment NM109)

Please be sure to include the location where the service being claimed was rendered.

number three icon Please be sure to:

  • Include your tax ID
  • Double check the ICD or diagnosis code to make sure it contains the correct digits.
  • Enter time, not units, when submitting claims for anesthesia services.
  • Make sure the member's ID number is correct.

Claims Filing

Claims can be filed electronically or via mail.


Electronic claims submission

Electronic claim submission allows for quicker processing and payments. We offer two Electronic Data Interchange (EDI) options. Contact them directly to register for electronic claim submission to Martin's Point.

Office Ally

Office Ally

1-866-575-4120

(Martin's Point Payor ID: MPHC1)

Relay Health

Relay Health, a division of Optum Insight

1-800-527-8133

(Martin's Point Payor ID: MPHC2)

Paper claims submission

Paper claims should be mailed to:

Generations Advantage

Martin’s Point Generations Advantage Claims Department
PO Box 11410
Portland, Maine 04104

US Family Health Plan

Martin’s Point US Family Health Plan Claims Department
PO Box 11410
Portland, Maine 04104

When submitting a claim for a patient who is also the subscriber:

Data should be submitted in Loop 2010BA (subscriber) only using the following fields:

  • Patient Last Name - 2010BA NM103
  • Patient First Name - 2010BA NM104
  • Patient ID # (code qualifier of "MI") - 2010BA NM108
  • Patient ID # - 2010BA NM109
  • Patient Date of Birth - 2010BA DMG02
  • Patient Gender - 2010BA DMG03

When submitting a claim for a patient who is a dependent of the subscriber:
  • Patient Last Name - 2010BA NM103
  • Patient First Name - 2010BA NM104
  • Patient ID # (code qualifier of "MI") - 2010BA NM108
  • Patient ID # - 2010BA NM109
  • Patient Date of Birth - 2010BA DMG02
  • Patient Gender - 2010BA DMG03
When submitting a claim for a newborn patient without a member ID number and who is a dependent of the subscriber:


Data should be submitted in Loop 2010BA (subscriber) and Loop 2010CA (patient) using the following fields:

  • Subscriber Last Name - 2010BA NM103
  • Subscriber First Name - 2010BA NM104
  • Subscriber code qualifier-  "MI" - 2010BA NM108
  • Subscriber ID # - 2010BA NM109
  • Subscriber Date of Birth - 2010BA DMG02
  • Subscriber Gender - 2010BA DMG03
  • Patient Last Name - 2010CA NM103
  • Patient First Name - 2010CA NM104
  • Patient Date of Birth - 2010CA DMG02
  • Patient Gender - 2010CA DMG03

Claim Adjustment, Replacement, and Void Requests

Information and instructions for electronic and paper requests for claims adjustment, replacement, and voiding.


Submitting claim requests

Electronic Claims

When submitting your request electronically, please make sure that within Claim Loop 2300:

CLM05-3: CLAIM FREQUENCY CODE

  • Must include the number ‘7’ if you want to adjust, replace or correct the original claim.
    Example: CLM*A37YH566*500***11::7*Y*A*Y*Y*C~
  • Must include the number ‘8’ if you want to void the original claim. 
    Example: CLM*A37YH566*500***11::8*Y*A*Y*Y*C~

REF - PAYER CLAIM CONTROL NUMBER

  • A new REF segment which contains a REF01 must contain the value 'F8' and REF02
  • Must contain the Martin’s Point claim number from the claim that is being adjusted, corrected, replaced or voided.
    Example: REF*F8*12345E06789~

NTE*ADD* - REASON FOR CLAIM

Add a new segment (NTE*ADD*) explaining the reason for the claim adjustment, replacement, correction or void request. For example:

  • NTE*ADD*Adjusted Claim – CPT Code change from 93010 to 99284~
  • NTE*ADD*Adjusted Claim – Added 3 new Service Lines and Charges~
  • NTE*ADD*Adjusted Claim – Removed service line~
  • NTE*ADD*Adjusted Claim – Modifier GF added to CPT Code 99284~
  • NTE*ADD*Voided Claim
Paper Claims

When submitting a paper claim request:


CMS/HCFA-1500 CLAIMS

  • Box 22 - Resubmission Code (Claim Frequency Code)
    Enter ‘7’ if you want to adjust, replace or correct a claim. Enter ‘8’ if you want to void a claim
  • Box 22 - Original Ref. No. (Original Reference Number)
    Must contain the Martin’s Point claim number from the claim that is being adjusted, corrected, replaced or voided.
  • Box 26 - Patient's Account No. (Patient Account Number)
    Must contain the patient account number from the original claim.

 

UB-04 CLAIMS

  • Box 3a - PAT CNTL #(Patient Control Number)
    Must contain the patient control number from the original claim.
  • Box 4 - Type of Bill
    Last digit must be ‘7’ to adjust, replace or correct a claim. Last digit must be ‘8’ to void a claim.
  • Box 64 - Document Control Number
    Must contain the Martin’s Point claim number from the claim that is being adjusted, corrected, replaced or voided.

Claim submission instructions

Timely filing for Participating Providers must refer to their provider agreement specific to timely filing requirements for claim submission and corrected claims that were previously submitted and denied due to incorrect or incomplete information. Non-participating Providers timely filing requirements for a clean claim is one year from the date of service and 65 calendar days of the first remittance date of the original claim for a corrected claim.

Electronic submission is strongly encouraged and, in most cases, no form is required. For example, if you want to change or add a code, billing amount, unit count, or modifier, simply submit another claim with the corrected information and the Martin’s Point claim number from the claim that is being adjusted or corrected.

If your adjustment request pertains to one of the following situations, please complete and submit our Provider Dispute Resolution Form along with any supporting documentation.

  • Code Review: Supporting clinical documentation is required.
  • Contract Terms: You believe the claim was not paid in accordance with negotiated terms.
  • Coordination of Benefits: The original claim could not be processed completely until information from another insurer was received.
  • Duplicate Claim: The original denial was due to a duplicate claim submission.
  • Filing Limit: The original claim was denied for untimely filing.
  • Request for Additional Information: The original claim was denied due to missing or incomplete information.
  • Retraction of Payment: You are requesting a retraction of an ENTIRE payment (e.g., wrong provider paid, incorrect provider information, patient not on provider panel, service not performed, etc.).

When submitting an adjusted claim, include all lines from the original claim that are still correct, not just the new or corrected lines. The adjusted claim will replace the original claim in its entirety. All payments on the original claim will be reversed and only those lines included on the adjusted claim will be reviewed for payment.


Additional important claim information

Additional important information regarding claims can be found here:

If we return a claim to you that does not include a Martin’s Point claim identification number, this means that the claim could not be adjudicated and therefore, was not entered into our claim system. If you wish to resubmit a returned claim, do not submit a corrected claim or a Provider Dispute Resolution Form.

Please submit an entirely new claim and do not use the words “Corrected,” “Replacement,” or “Adjusted” anywhere on the claim.

Authorization-Related Claim Denials - Please see the Retrospective Authorization instructions. 

If you wish to correct or dispute a claim that was denied for lack of authorization, do not submit a corrected claim or a Provider Dispute Resolution Form.

Non-participating providers: must initiate the claim appeal process on behalf of the member. See Grievances and Appeals. We cannot begin the appeal process without a Medicare Appointment of Representative Form [PDF]. Determinations are made within 60 calendar days of receipt of request.

Please also make sure the patient control number on your adjustment request also matches the original claim. We understand that some practice management systems may automatically assign a new patient control number each time you create a claim. However, our system will automatically pend your claim adjustment request if the patient control number does not match the original claim.

This will cause processing delays.

When submitting multi-page claims to Martin’s Point, please do not enter a total sum on each page of the claim. Always leave that field blank except for on the last page of the claim. The total charge on the last page of a multi-page claim should reflect the total of all claim lines on all pages within that single claim.

This applies to both HCFA/CMS-1500 and UB-04 claims. This rule also applies when you want us to correct, adjust, replace or void a multi-page claim.

Please do not submit your request as split claims. Your original, multi-page claim was submitted and processed as a single claim, with a single claim number. Accordingly, any adjustment requests regarding that claim number must be submitted as a single, multi-page claim, with a total only on the last page of the claim.

Again, the total charge on the last page of a multi-page claim should reflect the total of all claim lines on all pages within that single claim. 

We have incorporated CPT modifier logic into our claims processing system. The adjudication logic includes rejection of services that are submitted with inappropriate modifier(s) for the code in question. Please refer to your coding resources for guidance relating to proper use of modifiers.

Participating providers must submit service claims within 60, 90, 120, or 180 calendar days of the date of each service, in accordance with the provider’s participating agreement. Additionally, requests for claims adjustments must be submitted within 60, 90, 120, or 180 calendar days from the original remittance date for participating providers, per contractual agreement. Requests for claims adjustments from non-participating providers must be submitted within 60 calendar days from the original remittance date.

Additional Claim Filing Rules:

  • Claim filing deadlines are governed by the provider’s participating agreement, unless otherwise specified.
  • Members may not be billed for services if the claim is submitted after the allowed filing deadline.
  • For claims involving Coordination of Benefits (COB) or Motor Vehicle Accidents (MVA):
    • Claims must be submitted within 120 calendar days from the remittance date of the primary payer’s payment or denial.
    • A copy of the Explanation of Payment (EOP) from the primary insurer must be included with the claim.

Claim Corrections and Disputes

If there is an issue with a claim or you wish to dispute a denied claim, please review the information below.


Claim corrections vs. claim disputes

Do not file a dispute when the issue can be resolved with a corrected claim; corrected claims are the proper channel.

When to Submit a Corrected Claim:
  • You need to fix an error or omission on the original claim, such as wrong diagnosis, missing modifier, or incorrect date of service.
  • The claim was denied due to a billing error you can correct.
  • You're making changes to coding, units, charges, or other claim details.
When to Submit a Claims Dispute:
  • You believe the claim was processed incorrectly or denied incorrectly and no changes to the claim are needed.
  • You disagree with the denial reason (e.g., medical necessity, authorization, bundling, etc.).

Filing a provider claims dispute

A Provider Claims Dispute is a formal request asking the health plan to review a claim or service line due to a denial, a reduced payment, or other concerns related to how the claim was processed. When submitting a dispute, providers must select the appropriate review type (described below) to ensure the request is routed to the correct Martin’s Point team for timely evaluation.

This Martin’s Point Provider Claims Dispute Form is for post-service disputes arising from denied US Family Health Plan (USFHP) or Generations Advantage (GA) claims. The Provider Claims Dispute Overview/Form supports completion of the dispute process but does not replace official policies. Martin’s Point policies and Provider Manual take precedence and govern this process. The claims dispute process is separate from and does not replace Martin’s Point’s Appeal process. 

If you need to submit a claims dispute, fill out the following form:

2026 Form: Provider Claims Dispute Form [PDF] 

 

When to use the Provider Claims Dispute Form

Use this form only for post-service disputes where you believe a claim was denied improperly or processed incorrectly and no changes to the claim are needed. Do not use this form for the following:

  • Corrected Claims: Submit a Corrected Claim when updating codes, modifiers, dates of service, charges, or other claim details.
  • USFHP Retro Authorization Requests: These requests must be submitted via ProAuth.

Need Assistance? If you have questions about the form or claim submission process, refer to the Provider Claims Dispute Overview [PDF] guide or contact Provider Inquiry at 1-888-732-7364.



Filing Deadline & Dispute Timeframes

Providers must submit claims and disputes within specific timeframes based on participation status, the nature of the request (denial, underpayment, audit), and the level of review. Failure to adhere to these timeframes will result in a claim denial.

Participating Providers

  • 120 days from date of service (unless otherwise stated in Provider Agreement)
Martin's Point Audit Vendors

(including EXL, Optum IBR, Optum DRG)

  • 120 days from date of service (unless otherwise stated in Provider Agreement)
Providers (Participating and Non-Participating)

  • 120 days from the original claim remittance date.
Martin's Point Audit Vendors

(including EXL, Optum IBR, Optum DRG)

  • 30 days from date of an Audit Vendor findings letter
Participating Providers

  • 30 days from Plan's 1st Level response
Martin's Point Audit Vendors

(including EXL, Optum IBR, Optum DRG)

  • 60 days from Audit Vendor's response to 1st Level Dispute

Provider Claims Dispute Review Types & Keyword Dictionary

Selecting the correct review type determines what documentation you should submit with your dispute form, which helps ensure timely and accurate processing. An overview of Review Types, associated provider actions,  and required documentation can be found below, as well as a list of helpful keywords and definitions.

Use the table below to select the appropriate review type based on the nature of your request.

Dispute Review Types Provider Action / Required Documentation

Code Review

For claim denials based on codes submitted.

Denial examples: The primary service associated with this procedure has been denied due to submission of an outdated or vague diagnosis code, missing modifier, unlisted codes, or mismatched codes with a patient's gender or age

Submit Dispute Form—include rationale and supporting documentation with relevant medical records (as necessary) to explain and validate the submitted code.

(Please do not send the entire medical record)

Denied Authorization

For claim denials due to invalid or denied prior authorization for the service or date(s) of service (DOS).

Denial examples: Authorization not valid for date of service (DOS), Prior Authorization denied

Submit Dispute Form—include relevant documented rationale explaining why services were rendered following a denied prior authorization request. 

(Please do not send medical records; Plan reserves the right to seek additional records to demonstrate medical necessity, if applicable)

Do not use this form for Pre-Service Requests (please see UM for Pre-Service requests).

Failure to Obtain Authorization Due to Emergency or Urgently Needed Services (GA Only*)

For claims denials for failure to obtain authorization, where the provider can demonstrate that the services rendered were “Emergency and Urgently Needed Services” exempt from prior authorization requirements under 42 CFR § 422.113 and applicable CMS rules.

Denial example: No authorization on file.

*US Family Health Plan Claims Only: Disputes for failure to obtain auth will be treated as Retro Authorization requests, if timely, and must be submitted via ProAuth.

Submit Dispute Form—include relevant records demonstrating that the services rendered without prior authorization were emergency or urgently needed services, as set forth in 42 CFR § 422.113, and were medically necessary.

(Please attach reason for why prior authorization was not obtained and send applicable medical records)

Coordination of Benefits Review

For denials due to coordination of benefits issues, such as missing or incomplete primary EOB or conflicts with other health insurance coverage.

Denial examples: OHI must process claim first, resubmit with primary EOB, EOB does not match claim

Submit Dispute Form—send Corrected Claim with Primary EOB attached, or include other missing information. Do not submit a Dispute Form.

If 'EOB does not match'—submit Dispute Form, include rationale.

Timely Filing Review

Claim / line denied for being submitted after the plan's allowable filing deadline. This may happen if the original claim wasn't received, a denial was issued for a previously submitted claim, or a delay occurred due to coordination.

Denial examples: Claim submitted beyond timely filing limit, filing deadline exceeded

Submit Dispute Form—include relevant proof of timely submission such as clearing house reports, EOB from other payers, rejection letters, and any other necessary information.

Benefit Limitations or Non-Covered Services

For denials resulting from plan coverage rules, such as services that are excluded from benefits or that exceed defined benefit limits.

Denial examples: Service is not a covered benefit, Benefit limit exceeded, Excluded cosmetic procedure

Submit Dispute Form—include documentation showing why the service should be covered, such as relevant policy references, or other rationale.

Contractual or Pricing Review

For payment amounts that may not match provider agreement, or incorrect takeback / recoupments.

Denial examples: Paid below contracted rate, unexpected takeback of payment Modifier reduced payment incorrectly

Submit Dispute Form—include contract or fee schedule and a detailed explanation of the payment issue. Attach relevant remits showing discrepancy, if possible.

Duplicate Review

Claim/line denials identified as duplicate submissions.

Denial examples: Duplicate claim

If Incorrectly Identified as Duplicate—submit Dispute Form, include documentation showing why the service should be covered, such as relevant clinical notes, policy references, or other rationale.

Other / Case-by-Case Review

Use this category for disputes that don’t fall into any of the categories above and may need special handling or clarification.

Submit Dispute Form—include relevant information and supporting documentation.

Audit Vendor

Third party reviewing claims for accuracy or overpayment on behalf of Martin's Point (e.g., Optum, EXL).

 
Clearinghouse Report

Confirms claim submission via billing system.


Clinical Review

Medical necessity review based on criteria.


CMS LCD/NCD

Medicare coverage rules for services.


COB (Coordination of Benefits)

Determines payment order when multiple insurances apply.


Corrected Claim

Resubmission with updates (e.g., codes, modifiers, etc.).


Duplicate Claim

Same claim submitted more than once.


EOB

Explanation of claim payment/denial.

 
H&P

Summary of medical history and physical exam.


Modifier

Code added to clarify service details.


MP

Martin's Point.


MUE (Medicare Unlikely Edit)

Denial when billed units exceed typical amount.


OHI

Other health insurance the member holds.


Recoupment/Takeback

Recovery of overpaid funds.


Submitting a provider claims dispute

Provider claims disputes for Generations Advantage and US Family Health Plan must be submitted by mail to:

Martin's Point Claims Department
PO Box 11410
Portland, ME 04104

Disputes are not accepted via phone or eFax at this time.

 

Electronic Remittance Advices and Electronic Funds Transfer

The EDI partners listed above will work with you to set up Electronic Remittance Advices (835 files). Please contact them directly to request Martin's Point 835 files.

Electronic Funds Transfer (EFT) services are available to providers who have signed up to receive Martin's Point 835 files.

After you have received your first 835 file, please contact Provider Inquiry at 1-888-732-7364. If changes are made to your Bank Account (e.g., financial institution or a new account number), another form must be submitted.


Managing EFT transfers

To initiate, terminate, or change bank information for Electronic Fund Transfers, you must fill out and submit the Electronic Fund Transfer form. To obtain the form, send an email to [email protected] requesting the form be sent to you. 

Be sure to include your bank routing and account number, all required signatures, and all required fields on the form to expedite the EFT set-up process. You also need to attach a copy of a voided check and/or a bank letter.

Once the EFT form has been completed, please return the form and voided check/bank letter via email to [email protected] or FAX to 207-828-7870.


Coding and Billing

Martin’s Point Health Care follows correct coding and billing criteria for our US Family Health Plan and Generations Advantage programs.

Billing & Coding Errors

To promote correct coding and prevent inappropriate payments, we use software that more closely aligns our claims editing processes with correct coding and billing criteria established by the Centers for Medicare and Medicaid Services (CMS).

This software is updated regularly to remain current with correct coding and billing requirements.

For example, we apply editing rules for common errors such as:

  • Bundling: Items and services considered incidental to a physician service on the same date.
  • Unbundling: Determining whether two procedure codes are allowed to be billed for the same patient, on the same day, by the same provider.
  • Post-Op Surgery (Global Period): Surgical procedures rendered within predetermined follow-up time periods for services by the same provider, department, and specialty, with the same diagnosis code.
  • Medical Visit on Same Day as Procedure without Modifier: An evaluation and management (E/M) code billed on the same day as a procedure without a modifier to indicate that the E/M service was performed and documented as a significant, separately identifiable service.
LCD Rules

We also apply Medicare Local Coverage Determination (LCD) rules to claims for services rendered to Generations Advantage members in Maine and New Hampshire.

(NOTE: LCD rules do not apply to US Family Health Plan claims).

For example:

  • Diagnosis to Support Medical Necessity Edits: Will apply to certain procedures that require the use of specific diagnosis codes to support medical necessity for the service.
  • Primary/Secondary Diagnosis Code Edits: Will apply when LCD rules indicate a specific diagnosis code is required in the primary or secondary position to support medical necessity and/or to more fully define the patient’s condition.
  • Code Modifier Edits: Will apply when LCD rules require use of specific modifiers to communicate additional information about a service.
  • Frequency Limit Edits: Will apply to services that have limitations on how frequently they can be covered.

What kind of claims are affected?

The claim editing rules apply to both institutional and professional claims (UB-04 and CMS-1500) for services rendered to US Family Health plan and Generations Advantage members. LCD rules will apply only to Generations Advantage claims for services rendered in Maine and New Hampshire.

 

What is an LCD?

Under certain circumstances, Medicare fiscal intermediaries and carriers have the discretion to cover a particular service (i.e., determination that a service is reasonable and necessary). These coverage policies are issued in a document called a Local Coverage Determination (formerly, the Local Medical Review Policy). Local Coverage Determinations (LCDs) provide guidance that assists providers in submitting correct claims for payment. LCDs also outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. What are the LCD rules? Where can I learn more about them?

LCD rules can be found on the local carrier’s website or by contacting them directly. Following are the local carriers for Maine and New Hampshire:

Medicare Parts A & B: National Government Services, Inc.
https://www.ngsmedicare.com/NGS_LandingPage/

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

 

Coordination of Benefits (COB)

Coordination of benefits between the TRICARE, the US Family Health Plan (a TRICARE option), and Medicare.

Age-Eligible Medicare Members

Upon aging in to Medicare eligibility, these members are required to obtain Medicare A and B. These members do not pay an enrollment fee, and their medical service copayments are waived.

Members with Medicare have waived their rights to access care through Medicare with the exception of TRICARE non-covered benefits. Medicare is not considered secondary to the US Family Health Plan for coordination of benefits purposes and is generally not to be billed for US Family Health Plan members. Providers may bill Medicare for services rendered that are not covered by TRICARE.


TRICARE® Non-Covered Benefits

Members who are enrolled with the US Family Health Plan and have Medicare A and B, providers should only bill Medicare for TRICARE non-covered benefits (for example chiropractic care).


ESRD Medicare Members

Members under the age of 65 and qualifying for Medicare disability coverage, Medicare becomes primary the first day of the fourth month of the member's dialysis treatments. Members over the age of 65 with Medicare A and B receiving maintenance dialysis, Medicare becomes primary at that point. Providers should bill Medicare for services provided to a member who received Medicare benefits based upon a diagnosis of ESRD. The US Family Health Plan should be billed secondary.

US Family Health Plan and Commercial Health Plans and Medicaid

The US Family Health Plan is primary to the Medicaid program and secondary to all commercial health insurance plans such as Aetna, CIGNA, or Anthem. Federally sponsored health plans (e.g., Federal Blue Cross and Mail Handlers) are employee benefits and are primary to the US Family Health Plan. When these plans become Medicare supplements, the US Family Health Plan becomes primary as Medicare cannot be billed for non-ESRD US Family Health Plan members.


Subrogation and Third Party Liability

Providers are required to bill MPHC for all services furnished to a member, regardless of whether there is a third party involved. When a potential "third party liability" situation arises, the claim must indicate this in the appropriate section of the CMS-1500 or UB04 claim form. Upon receipt, Martin's Point Health Care will investigate to determine potential liability and the impact upon payment. Please do not bill the member or the member's attorney directly in such cases, even if requested by either.


Bill Requests

Should the member and/or attorney request a bill, direct him or her to our Provider Inquiry Department at 1-888-732-7364.

 

US Family Health Plan Point-of-Service (POS) Option

The US Family Health Plan Point-of-Service payment policy applies to most services rendered to our members by non-contracted (out-of-network) providers. Generally, US Family Health Plan members will pay a larger cost share for services rendered by an out-of-network provider than they would for the same services rendered by an in-network provider.

The exceptions to this policy are the following health care services which are paid at the in-network level and are not subject to Point of Service deductible and cost-share regardless of the provider's network status: Ambulance (ground only), Cardiac Catheterization, Diagnostic Procedures - Office or Outpatient Setting - (e.g., EMG, nerve conduction, digestive endoscopy, EGD, urodynamic studies, endoscopic ultrasound), Emergency Room Services, Home Health Services; Mammography (Diagnostic or Routine), and Urgent Care Center.

All other services rendered by non-contracted providers (even if pre-authorized) may be subject to the POS payment policy. Some non-contracted services may be authorized for payment at in-network rates based on medical necessity or network adequacy.

 

Hold Harmless

Hold Harmless information by plan can be found here:

Hold Harmless – US Family Health Plan

Participating US Family Health Plan providers have contractually agreed that, except for the collection of copayments, coinsurance, deductibles, payments for non-covered services, or payments for covered services provided after their agreement is terminated, in no event shall they bill, charge, collect a deposit from, or seek any recourse against any member or person acting on a member's behalf for covered services. Participating providers may bill or charge members for non-covered services if the member agrees in writing, prior to the provision of the services, to pay for the services.

US Family Health Plan contracted providers must obtain a signed Acknowledgement of Financial Responsibility Statement from the member in order to bill or collect for non-covered surgeries or TRICARE excluded services (see Member Handbook). General waiver forms signed at time of admission are not sufficient per TRICARE regulations. The waiver must be specific to the date of service and include the CPT code and the charge for the service.

As outlined in the TRICARE Operations Manual 6010.56-M, February 1, 2008, a network provider may not require payment from beneficiaries for any excluded services that the beneficiary received from the network provider and the beneficiary is "held harmless". Excluded or excludable services include TRICARE statutory exclusions (e.g. cosmetic procedures, certain durable medical equipment items or supplies) or services considered to be unproven or experimental. Providers are required to follow all applicable pre-authorization requirements, as Hold Harmless provisions apply.

Specifically, Chapter 5, Section 1, Network Development, states the following:

"A network provider may not require payment from the beneficiary for any excluded or excludable services that the beneficiary received from the network provider (i.e., the beneficiary will be held harmless) except as follows:

  • If the beneficiary did not inform the provider that he or she was a TRICARE beneficiary, the provider may bill the beneficiary for services provided.
  • If the beneficiary was informed that the services were excluded or excludable and he/she agreed in advance to pay for the services, the provider may bill the beneficiary. An agreement to pay must be evidenced by written records ("written records" include for example: 1) provider notes written prior to receipt of the services demonstrating that the beneficiary was informed that the services were excluded or excludable and the beneficiary agreed to pay for them; 2) a statement or letter written by the beneficiary prior to receipt of the services, acknowledging that the services were excluded or excludable and agreeing to pay for them; 3) statements written by both the beneficiary and provider following receipt of the services that the beneficiary, prior to receipt of the services, agreed to pay for them, knowing that the services were excluded or excludable). General agreements to pay, such as those signed by the beneficiary at the time of admission, are not evidence that the beneficiary knew specific services were excluded or excludable."

A TRICARE-approved, waiver of patient financial responsibility form is available in Forms and Documents.

Hold Harmless - Generations Advantage

Participating Generations Advantage providers have contractually agreed that, except for the collection of copayments, coinsurance, deductibles, payments for non-covered services, or payments for covered services provided after their agreement is terminated, in no event shall, they bill, charge, collect a deposit from, or seek any recourse against any member or person acting on a member’s behalf, for covered services. The Member shall be held harmless from any liability for payment and the provider shall look solely to Martin's Point Generations Advantage for payment for covered services.

This does not prohibit the collection of amounts due for services that have been identified in advance as non-covered, provided the Member has been notified of his/her financial obligation in accordance with the CMS regulations for Medicare Advantage organizations. CMS regulations require that a coverage determination be made with a standard denial notice for a non-covered Service. If prior to rendering the service, the provider obtains, or instructs the member to obtain, a coverage determination for a non-covered Service, the member can be held financially responsible for such non-covered services.

Members are also held harmless from financial responsibility for services rendered by providers who are not yet credentialed by Martin’s Point. Credentialing approval must be received prior to treating our members and each provider must be individually credentialed, regardless of the credentialing status of other providers in the same practice. After submitting a credentialing application, please allow 90 days for the process to be completed.

Claim Audits, Fraud, Waste, and Abuse

Martin's Point Health Care is firmly committed to ongoing prevention, education, detection, investigation, reporting, and elimination of fraudulent, wasteful and abusive claim practices.

On an ongoing basis, we evaluate care and services rendered to eligible beneficiaries to ensure that only medically necessary services are provided to eligible beneficiaries by authorized providers under existing laws and regulations, Defense Health Agency (DHA), Medicare instructions, and in accordance with nationally recognized standards.

Martin's Point Health Care has programs in place to make post-payment audits of provider claims. These post-payment reviews are conducted in a manner consistent with professional audit guidelines.

Martin's Point maintains policies related to these audits which are available by contacting the Network Management Department at 1-800-348-9804.


Disclaimer: As every claim is unique, the use of this policy is neither a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated.

Claims payment is subject to member eligibility and benefits on the date of services, coordination of benefits, referral/authorization, and utilization management guidelines when applicable and the adherence to plan policies and procedures and claims editing logic. Martin's Point Health Care (MPHC) has the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this disclaimer.

If such an audit determines that your office/facility did not comply with Martin's Point reimbursement guidelines, MPHC has the right to expect your office/facility to refund all payments related to non-compliance.



Provider Manual content reviewed and updated as of January 1, 2026.