Clinical Guidelines

Martin’s Point follows CMS and TRICARE guidelines for most coverage and reimbursement determinations.

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. 

There are several factors that impact whether a service or procedure is covered under a member’s benefit plan. Medical policies and clinical utilization management (UM) guidelines are two resources that help us determine if a procedure is medically necessary. These documents are available to plan members as a reference when interpreting claim decisions. For more information on our coverage decisions, 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.

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.