Clinical Coverage Criteria

Our coverage decision guidelines are reviewed annually by the Martin’s Point Utilization Management Committee.

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 utilize other guidelines. As a managed care organization MPHC medical criteria is determined using government program standards along with evidence based clinical resources.

Coverage & Utilization Management Criteria

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
• Coverage Determination Guidelines, Utilization Review Guidelines
• State and federal requirements
• The contract between us and the plan sponsor