The Point Issue 1 2019

HEDIS Medical Records Requests

Martin's Point will be faxing HEDIS-related medical record requests to network providers from January through early May 2019. We ask for your support in responding to the request as quickly as possible to allow a timely audit by our reviewers.

We will include a phone number for you to use should you have any questions and a secure fax number and physical mailing address to expedite delivery of your records to Martin's Point.

The HEDIS fax number is 207-828-7853 and is only monitored January 1 to May 9.

A reminder that at no time should medical records be faxed to the Provider Inquiry department. 

Thank you for your assistance with this effort and for the excellent care you give our health plan members.

Myths and Misconceptions: Clarifying New CMS Opioid Policies for Medicare Plans

Effective January 1, 2019, CMS enacted new policies regarding opioid prescribing for all Medicare plans with Part D coverage. Below are some common misconceptions about and clarifications of these new policies:

MYTH: Medicare now limits all opioid prescriptions to a 7-day supply. 

  • For Generations Advantage members, an opioid prescription will only be limited to a 7-day supply for those who have not filled an opioid prescription within the last 90 days. These patients are considered opioid naïve.
  • If there is a medically necessary reason for patients who appear opioid naïve to receive more than the initial 7-day supply, as recommended by the CDC, a provider can request an exception for Generations Advantage members.
  • Pharmacists can also override this 7-day limit for Generations Advantage members if they know the patient is not opioid naïve. For example, this may occur for patients who are new to Generations Advantage but have been taking opioids.
  • This 7-day limit is only for initial prescriptions for opioid naïve patients. This limit will NOT be in place for every opioid prescription.

MYTH: “Medicare is forcing all patients to taper their opioid prescriptions.”


  • The decision to taper opioids must be made by the prescriber and patient on a case-by-case basis.
  • CMS is following the CDC-recommended guideline of a maximum of 90 Morphine Milligram Equivalents (MME)/day. For Generations Advantage members, opioid prescriptions greater than 90 MME/day will require a review by the dispensing pharmacist with the prescribers. Once reviewed and determined appropriate, the dispensing pharmacist can place an override and dispense the opioid.
  • Exclusions: patients who are residents of long term care facilities, in hospice or palliative care, or being treated for active cancer-related pain are excluded from these limits. 
    CMS has published training materials for prescribers, pharmacists and patients at the following website:

Clarification: Claims Coding

Please note that we require participating providers to code claims submitted to Martin’s Point Generations Advantage in the same way that you would code the claim were it being submitted to original, fee-for-service Medicare, including the use of applicable modifiers. Martin’s Point Generations Advantage contracts generally refer to payment based on some percentage of the “Medicare rate,” “Medicare allowable rate,” “Medicare allowable amount,” “Medicare allowed amount,” “Medicare payment,” “Medicare physician payment,” “Medicare physician fee schedule,” “Medicare RBRVS payment rate,” or other terms that similarly reference a Medicare standard. As such, Martin’s Point Generations Advantage cannot properly calculate the payment rate for a given service unless the claim is coded in accordance with the coding standards under original, fee-for-service Medicare. 

Update Your Info Online with Provider DataPoint

CMS now requires us to contact our network providers on a regular basis to confirm that our directory information is up to date. We kindly request that you provide us with thirty (30) days advance notice of any changes to your provider/practice information whenever possible. Also, watch for reminders in future editions of The Point to notify us of any changes to your provider/practice information.

Provider DataPoint is our web-based provider data management tool that helps us maintain accurate provider directories and perform timely and efficient claim processing. Using this tool is an easy way to keep all your practice/provider information up to date and accurate.
PLEASE NOTE: We no longer accept updates, changes, and credentialing applications via email or fax. Please also note that radiologists, anesthesiologists, and midlevel providers (NP, PA) who do not practice as PCPs do not require credentialing.

Please use Provider DataPoint to:

  • Change your practice information, including name, phone/fax, address, billing information, NPI, etc.
  • Add or delete a location to your already-contracted practice/group
  • Change provider information, including name, specialty, panel status, add a language, etc.
  • Add a provider who requires credentialing to your practice
  • Terminate a provider from your practice/group
  • Check the status of a previously submitted data change request

To access Provider DataPoint, visit: Update Your Info

If you have any questions, please see the instructions on our website or speak to a Provider Representative.

Carrier-Priced Codes Policy 

Reminder: Our 2019 Carrier-Priced CPT codes have undergone their biannual update and providers will see a change in reimbursement for these codes. Carrier-Priced Codes are used in instances where federal programs, such as Medicare and TRICARE®, do not define reimbursement rates for a service, so the payer (Martin’s Point Health Care) determines reimbursement rates. Please refer to our Carrier-Priced CPT Policy located in the policy section of the provider website for details: Policies


Identifying Statin-Adherence Barriers for Your Patients

Martin’s Point Health Plan clinical pharmacists have been reaching out to our members/your patients regarding adherence to statins. Through these interactions, we are identifying common barriers to adherence. These barriers include, but are not limited to:

  • Lack of knowledge of disease/lack of symptoms
  • Lack of perceived benefit
  • Forgetfulness
  • Side effects
  • Medication cost
  • No refills/duration of therapy

We encourage you to have adherence conversations with your patients at each visit to identify if they are affected by any of these barriers. These conversations could potentially have a significant impact on the overall health of your patient. We have found that many patients perceive that they no longer need to take their medication when they have a “good” cholesterol reading or they have run out of refills. Others have clearly stated that they do not want to take their medication due to potential side effects. In these cases, alternate dosing or rechallenging may be warranted. Reinforcement of good adherence habits, including the use of daily reminder tools, would benefit all patients, but especially those with cost and forgetfulness barriers. Together, we can ensure optimal outcomes for your patients and our members. 

Comprehensive Visit Program Continues in 2019

$100 Incentive for Improving Quality and Medical Documentation through Annual Comprehensive Health Assessments 
We are pleased to announce that we will continue our Comprehensive Visit Program for 2019. This program supports the annual assessment of the health status of our qualifying Martin’s Point Generations Advantage members—promoting their health while ensuring compliance with CMS documentation requirements for Medicare Advantage plans. Visit to learn more.

Thanks for the Part You Play in Our 5 Stars

Martin’s Point Generations Advantage 2019 plans are the only Medicare Advantage plans in northern New England to have earned a 5-Star quality rating from Medicare. Earning 5 Stars is not something a health plan can do on its own and we want to thank you for the important part you played in making it possible.

How Your Work Connects to Medicare Star Ratings

The daily work you do to provide excellent care to your patients is directly connected to many of the measures CMS considers in its Star Rating process:

Delivering preventive care, including annual physical exams, recommended screenings, tests, and vaccines
Following best practices for diabetes care—monitoring A1C, kidney function, and annual retinal eye exams
Closely managing medication adherence for chronic conditions
Educating patients on fall risks and bladder control
We appreciate the focus you place on these care practices that are so important to the health of your patients and our members.

NOTE: Our 5-Star Generations Advantage plans are available for enrollment all year long throughout Maine and most counties in New Hampshire.