The Point Issue 2 2021

Posted 06/03/21
Doctor seeing patient

For more of The Point Provider Newsletter


  • Thank you for a successful HEDIS Season!
  • Smoking Cessation—Our Plan Benefits Can Help Your Patients Quit
  • Controlling Blood Pressure: Obtaining an Accurate BP Reading
  • Use of Imaging in Low Back Pain
  • TRICARE® For Life plus Medicare Advantage Claims Processing: What You Need to Know
  • Digital Authorization Management Available
  • COPD Transitions of Care Program:
  • Comprehensive Visit Program Expands Visit Types Qualifying for Incentive
  • Want Timely Claim Payments and New Patient Growth?
  • Just for Kids: Childhood and Adolescent Immunization
  • Thank you for a successful HEDIS Season!

    Martins Point Health Care thanks all practices that participated in the HEDIS medical record retrieval campaign over the last year. We value our partnership with you to provide great care in our communities.

    As we move forward through 2021, Martins Point will be requesting additional records for both risk adjustment and quality purposes. Your dedication to participate in chart access has huge impacts on our ability to provide an accurate and complete reflection of the care provided to our members.

    As year-round record requests increase, shared Electronic Medical Record (EMR) access offers an excellent way to decrease the burden of medical record retrieval for practices and the health plan. This safe and secure approach of sharing member information limits unnecessary information being released when entire medical records are sent via fax or mail. Sharing EMR access reduces the cost of sending medical records and helps increase recapture of conditions and quality-gap-closure rates to support optimal care delivery. 

    Please, let us know! For more information or to notify us how your organization would like to receive requests from us and how you’d like to share records with us, please contact Kristy Smith, RN BSN, HEDIS Administrator at [email protected] or Lisa Andrews, CPC Manager of Risk Adjustment and HEDIS Operations, at [email protected].

    Smoking Cessation—Our Plan Benefits Can Help Your Patients Quit

    Cigarette smoking is the leading cause of preventable death in the United States.1 Although cigarette use has decreased significantly, CDC data from 2017 tells us that around 34 million American adults (or 14% of the population) admit to daily or occasional cigarette use.2 To best serve our communities and mitigate this public health burden, it’s important to offer smoking cessation resources to patients at every office visit. 

    Quit attempts using pharmacotherapy are associated with better outcomes than those without medication assistance; and a 2020 US Surgeon General’s Report suggests that combination pharmacotherapy may increase the likelihood of quitting.3 One such strategy is to combine a scheduled, long-acting agent with an as-needed, short-acting agent to assist with cravings. Examples of long-acting or scheduled therapies include varenicline, bupropion, and the nicotine patch. As needed, short-acting therapies include nicotine-containing products (e.g., gum, lozenges, inhalers, and nasal spray). 

    All first-line pharmacotherapies are covered under the Generations Advantage and US Family Health Plan formularies. The details of coverage are listed in the table below.

    • The US Family Health Plan covers all of the agents as noted below for members 17 years of age or older. The member must use a Martin’s Point Pharmacy.
    • On all Generations Advantage plans, agents are available by prescription or eligible to be purchased using the member’s quarterly benefit to purchase over-the-counter (OTC), CVS-brand products.

    Martin’s Point Coverage for Smoking Cessation Medications

    Therapeutic   RX/OTC Generations Advantage US Family Health Plan
    Bupropion SR (Zyban)
    RX  Tier 2 Copay $0 copay, 60-day quantity limit, 
    max 2 quit attempts*/year
    Varenicline (Chantix) RX Tier 4 Copay with Prior Authorization $0 copay, 60-day quantity limit, 
    max 2 quit attempts*/year
    Nicotine Patch RX Non-formulary, use OTC benefit $0 copay, 60-day quantity limit, 
    max 2 quit attempts*/year
    Nicotine Gum
    Nicotine Lozenge
    RX Non-formulary, use OTC benefit
    $0 copay, 60-day quantity limit, 
    max 2 quit attempts*/year
    Nicotine Inhaler          (Nicotrol) RX Tier 4 Copay
    $0 copay, 60-day quantity limit, 
    max 2 quit attempts*/year
     Nicotine Nasal Spray (Nicotrol) RX  Tier 4 Copay   $0 copay, 60-day quantity limit, 
    max 2 quit attempts*/year

    *A “quit attempt” is considered a 120-day supply.

    Controlling Blood Pressure:
    Obtaining an Accurate BP Reading

    Obtaining accurate blood pressure (BP) readings in the office can be challenging. Improper technique and the so-called “white coat effect” result in unusable data and wasted time for staff. Some simple suggestions for obtaining accurate BP readings are listed below:

    Prepare the patient

    • Ask patient to empty his or her bladder, if needed.
    • Confirm patient has not had nicotine, caffeine, alcohol, or vigorous exercise in previous hour.
    • Position patient comfortably with legs uncrossed in chair with back and arm support.
    • Place the BP cuff on bare arm one inch above the antecubital fossa with the midline of the bladder over the brachial artery.
    • Support the arm so the cuff is at the level of the mid-sternum.
    • Ask the patient not to speak or move while the cuff is being inflated and deflated.

    Employ best practices for blood pressure measurement

    • Wait five minutes after applying the BP cuff before taking the initial BP reading.
    • Wait five minutes and recheck if the initial BP reading is elevated; document the 2nd reading.
    • Size matters—confirm your office has BP cuffs that will fit all your patients.
    • Consider the impact of terminal digit preference, random error, and bias when recording BP values.
    • Advise patients to avoid wrist and finger BP monitors for home readings.

    Use of Imaging in Low Back Pain

    Guidelines for imaging of patients with low back pain (LBP) have been adopted and published by the American College of Radiology, the National Institute for Health and Clinical Excellence, and the American College of Family Practice, among many others. 1,2,3,4 

    All stress the following principle:
    Routine imaging of patients with LBP should not be undertaken within the first six weeks of presentation, unless there are signs and symptoms of severe or progressive neurological deficit, cancer, cauda equina syndrome, infection, or fracture. 

    a. Early advanced imaging studies are indicated for all the above except fracture.
    b. Early plain film studies are indicated for fracture suspected after trauma or in the setting of osteoporosis, cancer, or chronic steroid use.

    We encourage clinicians to take the time to discuss the risks and benefits of imaging with their patients. A short conversation about the risks of radiation, expected time frames for recovery, and recommended treatments can go a long way in helping inform shared treatment decisions. 

    Highlights from the American College of Physicians clinical practice guideline of noninvasive treatments for acute, subacute, and chronic low back pain state5 that:

    • Acute back pain is defined as lasting fewer than four weeks. Subacute back pain lasts four to 12 weeks.
    • Most patients with acute back pain have self-limited episodes that resolve on their own. 
    • Symptoms usually improve within the first month regardless of treatment.
    • Clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence).
    • If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

    1American College of Radiology, Committee on Appropriateness Criteria, “Low Back Pain,” Originally published 1996, updated 2015.
    2 Bigos, S. et al., “Acute Low Back Problems in Adults,” Clinical Practice Guideline No. 14, AHCPR Publication No. 95-0642. Rockville, Md.: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994. 
    3 American Academy of Family Practice, “Imaging for Low Back Pain, Choosing Wisely,” 2020.
    4 National Institute for Health and Clinical Excellence, “Low back pain: Early Management of Persistent Non-specific Low Back Pain,” May 2009.
    5 Qaseem, Amir, Timothy J. Wilt, Robert M. McLean, and Mary Ann Forciea. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of Internal Medicine 166, no. 7 (2017): 514-30. Accessed August 7, 2017. doi:10.7326/p17-9032.


    TRICARE® For Life plus Medicare Advantage Claims Processing: What You Need to Know

    You may have noticed that more of your patients are choosing to use a Medicare Advantage plan instead of Original Medicare with their TRICARE for Life (TFL) benefits. Medicare Advantage plans are very attractive to military retirees because of the additional benefits not included in Original Medicare or TRICARE®, but there is an important distinction in the way claims are processed. 
    Here’s what you need to know:

    • Patients covered by Original Medicare or Medicare Advantage plans along with TFL should always present both their Original Medicare or Medicare Advantage card and their military identification card when receiving medical care.
    • TFL is administered by Wisconsin Physician Services (WPS).
    • Original Medicare and TFL: Your practice bills Medicare and then MEDICARE bills WPS for the remaining balance.
    • Medicare Advantage and TFL:  Your practice bills the Medicare Advantage company who will pay their contracted amount and produce an EOB. Then YOU will bill WPS for the remaining balance. 
      • You can submit claims to WPS through EDI (Electronic Data Interchange) and receive payments via EFT (Electronic Funds Transmission).  For more information, visit or call WPS at 1-866-773-0404.
      • For services covered by both TRICARE and Original Medicare or Medicare Advantage, the patient will have no out-of-pocket costs, including office visit copays. 

    Note:  If your practice is in Maine or New Hampshire, you may be seeing patients with our Martin’s Point Generations Advantage Alliance (HMO) Plan which has been specifically tailored for the military population.

    Digital Authorization Management Available

    Martin’s Point has an online authorization management tool that allows you to submit digital authorization requests using an easy, online process and receive real-time responses and updates. 
    The online tool is intuitive and interactive, guiding you through the submission process. Time-saving features include:

    • Searchable list of services requiring authorization by code
    • Electronic submissions of authorization requests and supporting clinical documentation
    • Real-time status updates of submitted requests
    • Authorization pre-screening—instant notification if an authorization is not required or a duplicate authorization exists

    All providers who have access to the Martin’s Point Provider Portal can enter authorization requests through the online tool for Generations Advantage and/or US Family Health Plan members.

    Some services must be authorized by the Plan BEFORE the service is delivered. Authorization by the Plan means the Plan has reviewed a request for a particular service and has determined that it is both medically necessary and covered under the Plan’s benefits. It is the provider’s responsibility to request Plan authorization to ensure the Plan approves the delivery of the proposed service and will cover it.  The plan offers digital authorization management for ease and efficiency, including a searchable list of services requiring authorization.

    The online tool is not used for behavioral health or advanced imaging services.
    Behavioral Health authorizations will continue to be performed through our partners at Behavioral Health Care Program (BHCP). BHCP can be contacted at 1-888-812-7335 for US Family Health Plan members and 1-800-708-4532 for Generations Advantage members.
    Advanced imaging authorizations for our Generations Advantage members will continue to be performed for the following services through our partners at eviCore:


    • Advanced Imaging (CT, MR, PET)
    • Nuclear Medicine

    eviCore can be contacted at 1-888-693-3211.
    If your organization does not currently have a local administrator for the Martin’s Point Provider Portal but would like to have access to our online authorization tool,  please follow this link to register for access:


    COPD Transitions of Care Program

    Your qualifying patients may receive outreach from us regarding pharmacotherapy management after an inpatient discharge.

    Martin’s Point Health Care has found that beneficiaries with COPD are at risk for adverse outcomes when transitioning from the inpatient setting to home. Our COPD Transitions of Care program is designed to help mitigate this risk through targeted interventions, including using HEDIS recommendations for pharmacotherapy management of COPD exacerbation after discharge.

    We wanted to remind you about this important program as you may be contacted by a Martin’s Point Care Manager or Health Plan Pharmacist regarding your patient’s treatment plan. Participating patients may also reach out to you with questions. We appreciate your involvement as we both provide services and resources to keep our members/your patients as healthy as possible.

    Which patients qualify?
    We use the following claims data to identify those who meet the HEDIS eligible-population criteria: Age 40 and older with COPD who had an acute inpatient discharge or an Emergency Department (ED) encounter with a principal diagnosis of COPD.

    What are we checking for?
    Once identified, we review the members’ medical records to determine if they have received the HEDIS-recommended care, including the following.

    • Had spirometry testing completed to diagnose COPD or within 180 days post discharge
    • Been prescribed both of the following:
      • a systemic corticosteroid and have filled the prescription within 14 days of discharge
      • a bronchodilator and have filled the prescription within 30 days of discharge
        • Per the 2021 GOLD Global Strategy for Prevention, Diagnosis and Management of COPD: maintenance therapy with a long-acting bronchodilator should be initiated as soon as possible before hospital discharge for management of exacerbations

    What do we do?
    For beneficiaries whose records show gaps in care, we reach out by telephone in an attempt to reduce COPD complications which could lead to readmission. The outreach provides the following:

    • Education—to ensure understanding of the dosage, timing, importance of adherence
    • Medication adherence assessment—offering formulary alternatives and referring to prescription-access programs to address inhaler costs
    • Medication reconciliation
    • Complete medication review—to ensure the member has a rescue inhaler on hand and to address high-risk medications, drug interactions, and any other potential gaps in therapy
    • Care coordination
    • Promotion of lifestyle changes
    Results so far:
    Since initiation of this program, we’ve seen improvements in prescribing practices and medication adherence for program participants in the cases of bronchodilators and, more significantly, of systemic corticosteroids. Due to the pandemic, spirometry testing has been a challenge with the drop off of in-person visits. We hope to see performance on this measure rebound as members return to pre-pandemic visit levels.
    If you have any questions regarding this program, please contact Health Plan Quality at 1-866-484-2788.

    Comprehensive Visit Program Expands Visit Types Qualifying for Incentive

    The Comprehensive Visit Program is a provider incentive program supporting 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. For added flexibility due to COVID-19, we expanded our qualifying visit types. To learn more about the program and these changes, visit our Comprehensive Visit Program page.

    Want Timely Claim Payments and New Patient Growth?

    Always keep your provider directory information up to date. We make it easy!

    CMS requires us to regularly contact our network providers to confirm the accuracy of our directory information. Up-to-date directory information helps our members find new providers when they need care and ensures more timely and accurate claims processing.

    There are two convenient, online tools you can use to keep your NPI-related practice/provider information accurate:

    1. Provider DataPoint: Please use our web-based provider data management tool to submit real-time changes:

    • Change your practice information, including name, phone/fax, address, billing information, NPI, etc.
    • Add/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 

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

    2. National Plan and Provider Enumeration System (NPPES): CMS now allows providers to use the NPPES to certify their NPI data. Information and FAQs about using NPPES as a reliable source for provider directory data are available at Please direct questions about the NPPES to Jeremy Willard at [email protected].

    Tips for Practice Administrators

    • Create a monthly tickler reminder to check the accuracy of your provider/practice information in Provider DataPoint.
    • We no longer accept NPI-related updates/changes and credentialing applications via email or fax. They must be submitted online via Provider DataPoint.
    • Radiologists, anesthesiologists, and midlevel providers (NP, PA) who do not practice as PCPs do not require credentialing.
    • Please provide 30 days advance notice of changes to your provider/practice information when possible.

    Just for Kids: Childhood and Adolescent Immunization

    One preventive health mainstay particularly hard hit by the pandemic is pediatric immunizations. As their partner in health, we are urging our US Family Health Plan members to make sure to schedule any vaccinations for their children that they may have delayed in the past year. We have added a pediatric health resource to our website which includes recommended immunization schedules, along with recommended well-child visits, pediatric mental health resources, and more. You can check out our Pediatric Health page for more information.