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 to.

 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 on utilization management decisions, visit out Clinical Guidelines.

 Payment Policy

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

  Questions? We're here to help.

If you have questions or need more information about Martin's Point Health Care policies, contact our Provider Inquiry Department at1-888-732-7364.

Additional Resources

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

Medical Policy Center

Durable Medical Equipment (DME): NHIC, Corp.

https://med.noridianmedicare.com/web/jadme

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