Claims
Our payment policies are generally consistent with Medicare and TRICARE.
For more information about Medicare coverage and reimbursement rules, please visit the Medicare Learning Network.
For more information about US Family Health Plan coverage and reimbursement rules, please visit the Code of Federal Regulations.
Need additional information or have questions?
Read more in the Provider Portal User Guide [PDF] or Contact Us.
Claims Status and Remittance
Electronic Claims
Relay Health
Relay Health, a division of Optum Insight
(Martin's Point Payor ID: MPHC2)
Electronic Funds Transfer / Direct Deposit
Electronic funds transfer (EFT) service, also known as direct deposit, is available to providers who have first signed up to receive Martin’s Point ERAs/835s. To request EFT service, please complete and submit the EFT/Direct Deposit Authorization Form found in the Forms and Documents section.
Electronic Remittance Advice (835) Provider Guide
Our Electronic Remittance Advice (835) Provider Guide found in the Forms and Documents section should make it easier for you to understand Martin’s Point 835 files. It is a searchable PDF that maps industry-standard adjustment reason codes to the corresponding Martin’s Point claims editing rules and remarks on our 835 files.
National Uniform Claim Committee 1500 Claim Reference Instructional Manual
Paper Claims
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
.
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.
- Pre-Service Requests: For Pre-Service requests, see Utilization Management.
- 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.