Utilization Management

Coverage and Utilization Management Decisions

We determine coverage decisions, including medical necessity decisions, on:

  • Member’s plan and benefits
  • Medicare coverage guidelines including National Coverage Determination (NCD) and Local Coverage Determination (LCD) guidelines
  • TRICARE Manuals
  • Coverage Determination Guidelines, Utilization Review Guidelines
  • State and federal requirements
  • The contract between us and the plan sponsor

Our employees, contractors, and delegates do not receive financial incentives for issuing non-coverage decisions or denials.  We do not offer incentives for underutilization of care/services or for barriers to care/service.

We do not hire, promote, or terminate employees based on whether they deny benefits. MPHC will apply objective and evidence-based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. We use tools such as Centers for Medicare and Medicaid (CMS) National and Local Coverage Determinations, TRICARE policy, and third-party resources (such as MCG Care Guidelines and other national guidelines) as well as Martin’s Point Health Care internal medical guidelines to assist us in administering health benefits and determining coverage.  These guidelines are reviewed annually by the Martin’s Point Health Plan Clinical Quality Management Committee (HPCQMC).  If you have questions or would like a paper copy of these guidelines, please call 1-888-339-7982.


A referral is not the same as an authorization request or approval. A referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. All referrals should be documented in the member's medical chart or electronic health record. A referral does not imply or guarantee payment

US Family Health Plan Referrals

The US Family Health Plan is built upon the relationship between the member and the PCP. The PCP is responsible for coordinating all patient care and making initial referrals for specialty care. Specialists, in turn, are responsible for communicating their findings, plans of care, and progress back to the PCP.

Resources regarding coverage for prescription drugs, mental health/substance abuse treatment, and outpatient treatment can be found here:

US Family Health Plan Members must receive a referral from their PCP before seeing any other provider or specialist. If no referral is obtained, the beneficiary will be subject to a higher point- of-service cost-share.  Please view the Member Handbook for complete details.

Referrals are not needed for some care such as Urgent/Emergent Care, Routine Preventive Services, and Office Based Mental Health.  Benefits can be checked using the provider portal if unsure whether referral is required.

Referrals to Participating Specialist: Referrals to participating specialist may be submitted directly to the participating specialist. The in-network specialist will submit the referral information on their claims to Martin's Point utilizing box 17 or electronic equivalent.

Referrals to Non-Participating Specialist: When a US Family Health Plan Provider is unable to be seen by a participating provider or facility, referrals to non-participating specialists will need to be submitted through ProAuth, our online referral and authorization portal. Out-of-network specialists should submit the referral information on their claims to Martin’s Point utilizing box 17 or electronic equivalent.

To find out if a provider or facility participates in our network, check our online directory or call 1-888-732-7364.

Generations Advantage Plan Referrals

Generations Advantage HMO plan members are required to select a PCP and to obtain referrals in advance from their PCP for most covered services. Self-referrals are only allowed in certain situations. Referral requirements vary by plan. Please view the individual plan documents for complete details. Whenever possible, please refer Generations Advantage members to a participating provider or facility. To find out if a provider or facility participates in our network, check our online directory or call 1-888-732-7364.

Coverage Decisions

Some plans require prior authorizations of select services and procedures through a pre-service clinical coverage review. You can check authorization requirements by code through the provider portal or through our ProAuth tool.

For urgent/concurrent admissions, admitting providers please be sure to notify the Martin's Point Health Management department of all urgent hospital admissions within 24 hours of admission (or next business day, if after hours or on weekends). Failure to notify in a timely manner may result in denial of payment for services provided.

For authorization of mental health/substance abuse services, please call the Behavioral Health Care Program at for the US Family Health Plan at 1-888-812-7335 or for Generations Advantage call 1-800-708-4532. For drug authorizations, visit our Pharmacy Forms and Documents page. For outpatient therapy), please use our Outpatient Therapy Prior Authorization request form found on the Forms and Document page.

Once we receive the request for prior authorization and the required clinical information, we can begin a clinical review for coverage.  We will notify you of the coverage decision within the time frame required by the Centers for Medicare and Medicaid, TRICARE policy, as well as our accrediting body NCQA.   

Clinical Coverage Review

If you submit the medical information needed with the request for prior authorization, your review will go faster.  To assist us in reviewing your request as quickly as possible please:

  • Return calls from our utilization review team and/or Medical Director.
  • Submit the correct and most specific code available for the services.
  • Comply with our request for additional information, including requests for medical records and imaging studies/reports:
  • If you receive our request for additional information, please supply the information within 24 hours unless the need for a shorter timeframe was discussed with a Utilization Review Nurse and/or Medical Director.

Behavioral Health

Martin's Point has partnered with the Maine Medical Center Physician-Hospital Organization and its Behavioral HealthCare Program (BHCP) to provide integrated behavioral health services to our members. Our goal is to connect patients with behavioral health resources that can help make the important connections between their emotional and physical well-being. BHCP is available to members for triage and referral 24 hours a day, seven days a week, through a toll-free telephone line:

US Family Health Plan: 1-888-812-7335
Generations Advantage: 1-800-708-4532

BHCP is committed to:

  • A care management focus
  • Utilization of criteria for review in a consistent manner 
  • Physician decisions made by local practitioners
  • Identification and support of a selected network of providers/vendors who demonstrate a shared commitment to high-quality, accessible care that will lead to the highest member satisfaction

When a Martin's Point health plan member inquires about coverage for mental health or substance abuse services, the Member Services team answers questions and refers him or her to the BHCP for authorization of services. BHCP also documents concerns, complaints, and appeals.

BHCP maintains its own network of contracted facilities and behavioral health specialists, including hospitals, psychiatrists, clinical psychologists, clinical social workers, licensed pastoral care counselors, marriage and family therapy counselors, clinical professional counselors, and other licensed clinicians. These providers and facilities are listed in the Provider Directories on Martin's Point health plan sites. Benefit coverage requires prior authorization for all services. Clinical criteria are used to determine medical necessity of behavioral health services.

It is the policy of the BHCP to address the individual needs of members. To that end, BHCP provides alternative clinical guidance to decision makers. In some instances, additional factors (e.g., age, comorbidities, complications, treatment progress, etc.) affect a clinical situation and the criteria are overridden to tailor the service to the member. This may occur with specific situations such as psychosocial situations, home environment, or lack of available services.

BHCP is committed to keeping member information confidential. All persons employed by BHCP are responsible and accountable for safeguarding this information in a consistent, thoughtful, and effective manner in accordance with state and federal law and the National Committee for Quality Assurance (NCQA). The BHCP follows all Health Insurance Portability & Accountability Act (HIPAA) regulations and requirements. For more information about Martin's Point behavioral health services, providers may call 1-800-538-9698.

For Generations Advantage Advanced Imaging authorizations only - eviCore healthcare (eviCore)

eviCore healthcare (eviCore) is an independent, specialty medical benefits-management company that provides utilization management services for Martin's Point Health Care.

eviCore will manage authorizations for the following imaging services for our Generations Advantage members.

  • Advanced Imaging (CT, MRI, PET)
Please note: Martin’s Point manages authorizations for cardiac advanced imaging. The quickest, most efficient way to obtain prior authorization for any of these services is through eviCore's 24/7 self-service web portal at https://www.evicore.com/resources/healthplan/martins-point.

Prior authorization can also be obtained via phone at 1-888-693-3211 or fax at 1-888-693-3210. Their call center is available at 1-888-693-3211 from 7 am–8 pm, ET, Monday through Friday. The following information must be submitted to eviCore in order to receive a medical-necessity determination:

  • Procedure requested
  • Patient, ordering provider, and rendering site information
  • Prior/ongoing treatments and their effects
  • Current clinical condition and recent test results

Retrospective Referrals and Authorizations

Retrospective referral and authorization requests are for services that have already been rendered (or will be imminently) for which prior authorization or referral was not obtained.

US Family Health Plan: We will review retrospective referral and authorization requests for all qualified care, before or after claim submission within 120 days of date of service or 120 days from claim remit date. Please refer to referral section above.

Both participating and non-participating providers may submit requests using our online authorization/referral tool or call the Health Management Department:

For Authorizations: 1-888-339-7982
For Referrals:  1-877-542-2654

Determinations are made within 30 calendar days of receipt of request.  

Generations Advantage:

Martin's Point will review payment disputes due to the failure to obtain prior authorization for beneficiaries only under the circumstances outlined in our online authorization tool or the Generations Advantage Authorization Dispute Form found on the Forms and Documents page.  

  • Documentation is required. "Not Enough Time" situations do not include when the provider renders a service that is considered experimental or investigational, and/or is not a covered benefit.

If your situation meets one of these criteria, please submit your retrospective authorization request with documentation that supports the criteria outlined above. We will assess if the criteria was met, if so we review coverage and if it requires medical necessity. We will first assess the criteria for coverage and then for medical necessity.

  • Participating providers seeking retrospective authorization for a Generations Advantage member must file a claim for that service, wait for claim denial, and then submit a Generations Advantage Authorization Dispute Form.
  • Non-participating providers seeking retrospective authorization (authorization was denied or not obtained and the service was rendered) can initiate an authorization dispute. Please see Non-Contracted Provider Claim Dispute Policy for dispute process and submission requirements.