The Point Issue 3 2020

Posted 10/23/2020

For more of The Point Provider Newsletter


  • Avoid Service Delays: Please Use Our Provider Portal!
  • Thanks, Again, for the Part You Play in Our 5-Stars
  • Deprescribing in Medication Management
  • Cervical Cancer Screenings Can Save Lives
  • Chlamydia Testing in Young Patients
  • Save Time: Know Which Providers DO NOT Require Full Credentialing!
  • Financial Help for Active-Duty Family Members with Special Needs: ECHO Program
  • FDA Issues Labeling Changes for Opioids regarding Naloxone
  • Reminder: Service Location Requirements on HCFA 1500 Claims Form
  • Reminder: Comprehensive Visit Program
  • Please Ensure Correct Coding for COVID-19-Related Claims
  • Want Timely Claim Payments and New Patient Growth?
  • TruCare ProAuth™
  • Improving Meaning and Quality of Life 
  • Annual Updates
  • Avoid Service Delays: Please Use Our Provider Portal!

    An Important Message from Jeffrey Polk, Vice President of Network Management

    Martin’s Point, like most health care organizations, is experiencing higher than normal call volume as we manage through the COVID-19 pandemic and all its implications. When calling into the Provider Inquiry team, you may experience unusual delays at this time, and we apologize in advance.  Unfortunately, this situation is likely to continue through the winter.

    Thankfully, our Provider Portal offers a convenient and quick alternative for accessing the most frequently requested information, including easy-to-use lookups for:

    Eligibility    •    Benefits    •    Claims    •    EOBs

    Using our Provider Portal offers significant efficiencies when compared to phone service:

    Phone Call to Provider Inquiry Using our Provider Portal
    On-hold wait times can be up to 10 minutes  No wait time – instant access
    Average duration of phone call = 8 minutes Average portal search 30 seconds
    Available 8 am–5 pm, Mon–Fri Available 24/7/365*

    *unless during required maintenance

    The source data you get through our Provider Portal is the same as what our Provider Inquiry representatives provide you, but you can access all the available information, not only what you specifically request. And the information you download/print comes with a reference number for your records.

    We strongly urge you to take advantage of our Provider Portal for the fastest service! For instructions on how to access and use the Martin’s Point Provider Portal and save time, please see our helpful Provider Portal Guide located under Forms & Documents section of our website. 

    If you have questions or need additional information regarding our Provider Portal solution, please contact Provider Relations at 1-800-348-9804.

    Thanks, Again, for the Part You Play in Our 5-Stars

    Martin’s Point Generations Advantage HMO-style plans are the only Medicare Advantage plans in Maine and New Hampshire to have earned a coveted 5-Star quality rating from the Center for Medicare & Medicaid Services (CMS) for 2021. Each year, CMS assesses all Medicare Advantage plans on over 50 measures in their Star Rating process, including quality of care, member experience, and customer service. Earning Medicare’s highest-possible overall rating 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 New Hampshire.

    Deprescribing in Medication Management

    Deprescribing is the supervised dose reduction or discontinuation of medications that may no longer provide a benefit or may cause harm to a patient and is an important tool in good prescribing practices. As more medications are added to a patient treatment regimen, it can lead to an increased risk for medication-related problems (including risks for falls, side effects, and hospitalizations). Optimizing a medication regimen through deprescribing can decrease medication burden and risk for negative side effects, improve quality of life, and save money.

    Pharmacists can be a great asset for developing a complete medication review, which can then be used to identify and prioritize medications which may no longer be needed.  Some medication regimens which may be appropriate for deprescribing include:

    • Long-term use of PPIs
    • Beers List medications in patients over 65
    • Medications with no indication
    • Duplicative therapies
    • Medications with unlikely benefit
    • Medications with drug or disease interactions

    Resources are available to practitioners who would like help reducing or stopping medications in appropriate patients. Consider reaching out to a clinical pharmacist for more information on accessing deprescribing tools and algorithms for a complete medication review.


    Cervical Cancer Screenings Can Save Lives

    Cervical cancer used to be the leading cause of cancer death for women in the US. However, in the past 40 years, the number of cases and deaths from cervical cancer have decreased significantly, thanks to early detection and treatment. Even with these advances, cervical cancer still claims lives every year—in 2017 the US had 12,831 new cases of cervical cancer with 4,207 deaths.

    Given the prevalence and the importance of preventive care in identifying members in early stages of cervical cancer or those who are at significant risk, we ask that providers be vigilant to assure our health plan members get appropriate and timely cancer screenings. CMS and NCQA also support and encourage these CDC-guided preventive screenings and provide recommendations and quality measurements based on the information below:

    Cervical cancer screening is recommended for patients:

    • Ages 21–30—cervical cytology every 3 years
    • Ages 30–64—cervical cytology performed every 3 years OR cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

    Patients can be excluded from this screening if there is clear documentation in the records showing they had any of the following in their medical history—with month and year noted: 

    • Hysterectomy with no residual cervix—a complete, total, or radical abdominal or vaginal hysterectomy 
    • Cervical agenesis
    • Acquired absence of cervix

    Cervical cancer screenings save lives. The decrease in the number of those diagnosed and survivability in those with a diagnosis of cervical cancer show the efficacy and importance of these screenings.

    1. CDC detailed report, 2017
    2. NCQA HEDIS Technical Specifications. 2020-2021

    Chlamydia Testing in Young Patients

    Discussion of sexually transmitted infections, along with any indicated testing, are  important parts of an annual wellness visit for any young person or person with multiple sexual partners. Chlamydia—one of the most prevalent STIs in the US—is most common in persons with a cervix in the 15-24-year age group (Centers for Disease Control Detailed Fact Sheet).

    Despite being the most-reported STI in the US, it is also underreported because most people who have chlamydia are asymptomatic. The dangers of untreated chlamydia include spreading disease to multiple partners, pelvic inflammatory disease, tubal factor infertility, ectopic pregnancies, and chronic pelvic pain (CDC).

    Due to the prevalence of the disease among young persons with a cervix and the dangers of untreated, asymptomatic chlamydia, the CDC, CMS, and NCQA recommend yearly chlamydia testing for members of this population who are under 25 and are either sexually active or have a prescription for birth control. NCQA and CMS are so invested in the identification of such persons with chlamydia that they have made a yearly test a reportable quality measure that follows CDC guidance (NCQA HEDIS Technical Specifications).

    The CDC recommendations are below:

    • Sexually active persons with a cervix age 25 or younger: Yearly testing. Retest when patient has new sex partner regardless of timing.
    • Pregnant persons: Test at first prenatal exam. If at high risk of infection—from changing sex partners or regular partner might be infected—test again later in the pregnancy.
    • All persons at high risk: People with multiple sex partners, who don't always use a condom; and/or who have anal/oral sex should receive frequent chlamydia screening. Other markers of high risk are current infection with another STI and possible exposure to an STI through an infected partner.

    As you schedule wellness visits for the year, please look closely at this age group and consider doing a chlamydia test in office. Prevention, discussion, and treatment will help decrease the spread and limit the damage that can be caused by untreated chlamydia.

    1. Centers for Disease Control Detailed Fact Sheet. 10/04/2016.
    2. NCQA HEDIS Technical Specifications. 2020-2021

    Save Time: Know Which Providers DO NOT Require Full Credentialing!

    There are a number of provider categories that do not require a credentialing application or advance notice of enrollment to be considered in-network for Martin’s Point health plans. These include the following:

    • Locum tenens or per diem providers: Because they serve on a temporary basis, they are not listed in our directory and do not require credentialing.
    • Part-time providers (less than weekly): Providers not meeting our requirement to be available for appointments on at least a weekly basis are not listed in our directory and do not require credentialing.
    • Mid-level providers NOT working as a primary care provider (PCP): Exceptions—the following DO REQUIRE credentialing: optometrists, midwives, audiologists, and mid-levels (NP, PA) working as a PCP and holding a panel. Generations Advantage ONLY: Chiropractors in Maine and New Hampshire DO REQUIRE credentialing.
    • Providers who do not accept appointments in an office setting: Providers who do not accept appointments in an office setting, including radiologists, pathologists, and anesthesiologists.
    • Rehabilitation therapists: Rehabilitation facilities are credentialed and claims are paid at the facility level. We do not credential individual rehabilitation therapists, (PT, OT, SP, SLT).
    • Hospitalists: Providers working strictly in an in-patient setting (hospital, nursing home, skilled nursing facility) do not require credentialing.
    • Family Medicine/Internal Medicine providers working in a specialty setting: FM/IM providers require credentialing only if they are practicing as a primary care provider (PCP). Only providers with training and certification in the specific group specialty require credentialing and will appear in the directory.

    The providers listed above are considered in-network for services performed at a contracted group. Martin’s Point loads the provider data from claims information and assigns an effective date of 90 days prior to the date of service. 

    As always, review our credentialing page before enrolling a provider to avoid unneeded data entry.

    Financial Help for Active-Duty Family Members with Special Needs: ECHO Program

    TRICARE™ Extended Care Health Option (ECHO) provides active-duty military families with financial help for beneficiaries who are diagnosed with moderate to severe intellectual disability, physical disabilities, or extraordinary physical or psychological disorders.

    • Members who qualify for ECHO are provided up to $36,000 per year to support services not covered by the basic TRICARE military health care program.
    • To be eligible for ECHO, military sponsors must be active duty, enroll in the Exceptional Family Member Program (EFMP) and register for ECHO with their regional contractor.
    • ECHO specialists in the Martin’s Point Health Management department help beneficiaries with enrolling in ECHO, getting access to care, locating providers, and using their benefit. Martin’s Point currently has 18 enrolled ECHO members, and we continue to expand our resources to support the needs of our members.
    • The Comprehensive Autism Care Demonstration covers applied behavior analysis (ABA) services for children with autism. To received ABA therapy, the member must enroll in the Exceptional Family Member Program (EFMP) and register in the Extended Care Health Option (ECHO).
    • To be covered by the ECHO program, all programs and supplies must be evidence based and all services require an authorization. One common request for ECHO members is for weighted blankets. At this time, weighted blankets are not a covered benefit. An example of a covered item would be medically necessary adaptive equipment. 

    For questions about ECHO at Martin’s Point Health Care, contact our Health Management department at 877-659-2403.

    FDA Issues Labeling Changes for Opioids regarding Naloxone

    On July 23, 2020, the US Food and Drug Administration (FDA) announced it is requiring that labeling for opioid pain medicine and medicine to treat opioid use disorder (OUD) be updated to recommend that, as a routine part of prescribing these medicines, health care professionals should discuss the availability of naloxone with patients and caregivers, both when beginning and renewing treatment.

    The required labeling changes recommend the following practices for health care professionals:

    Consider prescribing naloxone when:

    • Prescribing medicines to treat OUD
    • Prescribing opioid pain medicines to the following patients:
      • Those at increased risk of respiratory depression or opioid overdose, including those also taking benzodiazepines or other central nervous system depressants
      • Those with a history of OUD and/or opioid overdose
      • Those prescribed opioids who have household members, including children, or other close contacts at risk for accidental ingestion or opioid overdose
    • The FDA requires that these recommendations be added to the prescribing information for opioid pain medicines and medicines to treat OUD, including buprenorphine, methadone, and naltrexone.
    • Risk factors for opioid-induced respiratory depression include:
    • Recent emergency medical care for opioid poisoning/intoxication/overdose
    • Suspected history of heroin or nonmedical opioid use
    • High-dose opioid prescription (e.g., >90 mg. morphine equivalence (MME)/day)
    • Any methadone prescription to opioid-naïve patient
    • Recent release from incarceration
    • Recent discharge from opioid-detox or abstinence-based program
    • In methadone or buprenorphine detox/maintenance for addiction or pain
    • Any opioid prescription AND …
      • Respiratory diagnoses: Smoking/COPD/emphysema/asthma/sleep apnea/ other.
      • Renal dysfunction or hepatic disease
      • Known or suspected concurrent alcohol use
      • Concurrent benzodiazepine prescription or nonmedical use
      • Concurrent SSRI or TCA antidepressant prescription

    To calculate MME, there are many helpful websites.  One accurate website is through the Washington State Agency Medical Directors Group at

    Consider prescribing naloxone to help combat the opioid epidemic. If possible, also consider tapering any patient’s total MME below 90mg/day to decrease the risk of respiratory depression or overdose. Tapering slowly with a decrease of 10% per month for patients who have taken opioids for over a year is a good starting point. Tapering plans should be individualized to minimize withdrawal while continuing to manage pain. Please check with local state guidelines on prescribing naloxone.

    Reminder: Service Location Requirements on HCFA 1500 Claims Form

    As of 3/31/2020, Martin’s Point has required providers to submit the service location (Box 32) and servicing provider’s NPI (Box 32A) on all HCFA 1500 claim forms and electronic file types as required by the Medicare Claim Processing Manual, Chapter 26. If the boxes are not completed, the claim will be denied and sent back to the provider for correction. Requiring these fields helps ensure accurate reimbursement and timely claims processing. If you have questions concerning this change to claims or payment processes, please contact Martin’s Point Provider Inquiry at 1-888-732-7364.

    Reminder: Comprehensive Visit Program

    As we wrap up 2020 visits, please take an opportunity to participate in our Comprehensive Visit Program for eligible Generations Advantage members if you have not already done so. For added flexibility due to COVID-19, we expanded our qualifying visits types. To learn more about the changes made in 2020, visit We will be accepting 2020 Comprehensive Visit Forms until March 31, 2021.

    We are also pleased to announce that we will continue our Comprehensive Visit Program for 2021. 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.

    Please Ensure Correct Coding for COVID-19-Related Claims

    For the most accurate and timely claims processing, please ensure correct coding for your COVID-19-related claims. The most up-to-date guidance on correct diagnosis codes for confirmed and unconfirmed COVID-19 cases can be found on our COVID-19 PROVIDER FAQs available on our website.

    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 

    TruCare ProAuth™

    In August, we successfully launched TruCare ProAuth™, our new electronic authorization request tool, available at If you haven’t signed up for access to ProAuth, please call: 1-888-732-7365.  If you have any questions about what it can do for your office, please call 888-339-7982

    Improving Meaning and Quality of Life 

    Comprehensive Care Program – A PCP’s Experience

    W. Ross Wadland, MD at Martin’s Point Health Care

    Meet “Mary,” a typical patient of mine—and perhaps yours—a 78-year-old with diastolic heart failure, AFib, type 2 DM, and chronic pain with declining health. At her visits, I review over eight meds, follow up on diagnostic tests and sort through rotating chronic and acute complaints of dizziness, fatigue, incontinence, insomnia, and more.  We always touch on Mary’s first concern—her husband’s worsening dementia—as she is his primary caregiver.  All this while trying to apply the best evidence-based therapy and ensure a good follow-up plan.

    It’s frustrating to know these visits only skim the surface of the complex factors affecting Mary’s health. For patients like her, their homes—places we don’t see as their PCPs—are where healthy living starts and is sustained or begins to fall apart and fail.

    Fortunately,  Mary (and I) have access to the Generations Advantage Comprehensive Care Program (CCP)—a no-cost, longitudinal, chronic-disease wellness program where community-based RNs provide care and support in patients’ homes and across all care settings. With the goal of mitigating risk and preventing disease flare-ups that can lead to the need for urgent or emergent care, CCP nurses: 

    • Conduct in-person home visits, helping patients work toward their health goals and follow treatment recommendations
    • Provide advanced preventive care (medication review, symptom monitoring, education, and more)
    • Inspire hope and promote engagement by building relationships of trust and accountability with patients over time
    • Inform and collaborate with PCPs/care teams to coordinate and enhance care

    Over two years of having patients enrolled in this program, the CCP RNs have given me a much deeper understanding of my patients’ health in their homes—reducing barriers to medication and treatment plan adherence, catching missed diagnostic tests, helping with advanced directives, and much more.

    So many of our patients struggle with complex chronic medical conditions and numerous, expensive medications without the social support needed on a personalized basis to understand and optimize their health.  CCP is a remarkable program that gives our patients these supports with benefits that go way beyond health outcomes—improving meaning and quality of life.

    Do you have a patient like Mary? Our Comprehensive Care Program Could Help Both of You!

    If you have Generations Advantage patients (in the greater Portland and Brunswick areas) who might benefit from this program, please call the Martin’s Point Comprehensive Care Program at 207-828-2456 for more information.

    Annual Updates

    Martin’s Point strives to ensure our members and our network providers are well informed about our health plans. We update our website periodically to provide useful information and tools.

    Care Management

    RNs and social workers are available to partner with you to provide care management, disease management, and medication-adherence support for your patients. For more information, please visit Care Management. To refer a member or for more information, call 1-877-659-2403.

    Behavioral Health

    Martin’s Point has partnered with MaineHealth Accountable Care Organization and its Behavioral HealthCare Program (BHCP) to provide integrated behavioral health services to our members. Behavioral health providers and facilities may be found here.

    BHCP is available toll free to members 24 hours a day, seven days a week, for triage and referral:
    US Family Health Plan Members: 1-888-812-7335
    Generations Advantage Members: 1-800-708-4532

    Utilization Management

    The Utilization Management (UM) team is committed to ensuring that patients receive appropriate care for their medical conditions. UM decisions are based on evidence-based criteria designed to review the needs of patients based on their individual medical conditions. UM decisions are based only on appropriateness of care and existence of coverage. All medical reviewers follow these criteria and there are no incentives, financial or other, to deny care.

    Information on authorizations can be found at

    Criteria used for Utilization Management decisions are available through our Health Management department at 1-888-339-7982, Monday through Friday, 8 am–4:30 pm. Messages left after business hours will be responded to the next business day. Our fax number for UM-related issues is 207-828-7865.

    Member Rights and Responsibilities

    Martin’s Point ensures all new and existing members receive communication regarding their rights and responsibilities.

    Martin’s Point US Family Health Plan: We notify members of their rights and responsibilities via the US Family Health Plan Member Handbook and our emailed member newsletter. The Member Handbook and other important materials can be found here.

    Martin’s Point Generations Advantage: We notify members of their rights and responsibilities in their annual Evidence of Coverage document and on our website: Member's Rights

    Health Plan Quality Program 

    Martin’s Point Health Care strives to offer health plans that are among the best in the nation. We are committed to supporting the delivery of care and service that meets the highest standards for safety, effectiveness, and customer experience. We continually collect and analyze data in our effort to monitor our performance and identify areas for improvement. In collaboration with our network providers, we support effective and affordable screening and treatment practices to prevent health issues and manage chronic conditions.

    While we work to ensure the health of individual members, we are also concerned with the health of our overall member population and the well-being of our community. We offer an array of services ranging from nursing care management to broad interventions targeted at groups of individuals who have care “gaps” such as missed screening interventions. As we pursue this work, we follow clinical guidelines issued by nationally recognized expert bodies.

    For more information please visit here.


    The Martin’s Point Credentialing team (or its designated qualified agent) reviews facility and provider documentation to determine eligibility for participation in our health plan network. Martin’s Point recognizes the provider’s right to:

    • Review information submitted in support of their credentialing/recredentialing application (to the extent permitted by law)
    • Correct erroneous information
    • Receive the status of their credentialing/recredentialing application upon request (via phone or mail)
    • Review their credentialing file by scheduling an appointment (via phone or mail)

    More information is available at

    Providers may contact us at:
    Email: [email protected]
    Phone: 207-253-6930 or 1-800-348-9804
    Fax: 207-828-7873

    Martin’s Point Health Care
    ATTN: Credentialing Department 
    PO Box 9746
    Portland, ME 04104


    Our health plan formularies are frequently updated to keep pace with new clinical data and evolving drug classes. Our goal is to maintain a broad, clinically sound formulary and to help drive generic utilization to reduce pharmacy costs for your patients. We distribute revised formularies to our members on an annual basis and will inform members and providers when changes are made.

    Information on our pharmacy management procedures including drug authorization, step therapy and quantity requirements, and links to formularies can be found at

    Information on therapeutic interchange and step-therapy protocols for the US Family Health Plan are available at

    For authorizations or other questions related to pharmacy benefits, please call us at 1-888-732-7364