Clinical Guidelines
Medical Policies and Clinical UM Guidelines
Martin’s Point Health Care (MPHC) follows CMS and TRICARE guidelines for most coverage and reimbursement determinations. However, there are situations in which MPHC may utilize other guidelines. As a managed care organization, MPHC medical criteria is determine using government program standards along with evidence based clinical resources.
These resources are available to members, prospective members, and providers to assist in reviewing plan communications and/or decision notices regarding requested services. In addition, provider may visit our Provider Manual on Utilization Management.
When evaluating coverage and payment requests, Martin’s Point will review the relevant regulatory sources (CMS Medical Benefit Policy Manual, CMS Claims Processing Manual, etc.), National Coverage Determinations, and Local Coverage Determinations. In the absence of applicable coverage criteria from those sources, Martin’s Point may apply coverage criteria in its own internal medical and/or payment policies, and/or request additional information such as clinical trial outcomes, peer review articles, etc.
Martin’s Point Medical Policies can be viewed, by category, by visiting our Forms and Documents search tool.
Along with the documents Martin's Point maintains for coverage decisions, we may adopt criteria used by other organizations. Note that Martin's Point‘s medical policy will supersede in situations where we have developed a medical policy that addresses a service when one of the entities noted above has separate criteria.
Martin's Point Health Care Medical Necessity Criteria
Clinical UM Guidelines adopted by Martin's Point Health Care
Martin's Point Health Care Part B Step Therapy Clinical Guideline
Martin's Point Health Care Step Therapy Drug List
eviCore Imaging Guidelines - For Prior Authorizations with a date of service prior to 07/01/2024, please utilize the eviCore Authorizations Guidelines.
National Comprehensive Cancer Network (NCCN.org)
Optum Policies (Radiation Oncology and Specialty Pharmacy)