The Point Issue 3 2021

Posted 09/13/21

For more of The Point Provider Newsletter


  • Thanks, Again, for Your Help in Earning Our 5 Stars
  • Encouraging COVID-19 Vaccine for Pregnant People
  • Need to Check Claims Status, Eligibility or Benefits: Save Time, Use Our Provider Portal!
  • Reminder: Comprehensive Visit Program
  • Cervical Cancer Screenings Can Save Lives
  • Chlamydia Testing in Young Patients
  • Credentialing: Your Timely Response for Additional Information Is Needed
  • Reminding Our Members to Get Their Flu Shots
  • New Step Therapy Requirements for Part B Drugs
  • Want Timely Claim Payments and New Patient Growth?
  • “Hold Harmless” Guidelines for Martin’s Point Health Plans
  • Just for Kids: Financial Help for Active-Duty Family Members with Special Needs: ECHO Program
  • Just for Kids: Are Your Pediatric Patients Protected against the Flu?
  • Annual Updates
  • Thanks, Again, for Your Help in Earning Our 5 Stars

    Martin’s Point Generations Advantage HMO-style plans have, once again, earned a coveted 5-Star quality rating from the Center for Medicare & Medicaid Services (CMS) for next year. And, we’re proud to announce that our LPPO plan has also received 5 Stars for 2022!

    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. We want to thank you for the important part you play in making our 5-Star rating 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.

    Encouraging COVID-19 Vaccine for Pregnant People

    The Centers for Disease Control has released data on the safety and effectiveness of the COVID-19 vaccine citing that the mRNA vaccines (Pfizer and Moderna) are safe and effective in pregnancy. We encourage providers to recommend pregnant patients to get the vaccine as soon as possible to reduce severe risks of COVID illness and pregnancy complications. Updated information can be found on the CDC website.

    Need to Check Claims Status, Eligibility or Benefits: Save Time, Use Our Provider Portal!

    Our Provider Portal offers a convenient and quick self-service option for accessing the most frequently requested information, including easy-to-use lookups for:

    Eligibility    •    Benefits    •    Claims    •    EOBs •    Authorizations

    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 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.

    In addition to eligibility, benefits, claims, and remittance, you can submit and view authorizations.  To learn more about using the Portal for authorizations, please see our FAQ.

    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, 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.

    Reminder: Comprehensive Visit Program

    As we wrap up 2021 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 visit types. To learn more about the changes made, visit our Comprehensive Visit Program page. We will be accepting 2021 Comprehensive Visit Forms until March 31, 2022.

    We are also pleased to announce that we will continue our Comprehensive Visit Program for 2022. 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 our Comprehensive Visit Program page to learn more.

    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.The American Cancer Society’s estimates for cervical cancer in the United States for 2021 are:

    • About 14,480 new cases of invasive cervical cancer will be diagnosed
    • About 4,290 women will die from cervical cancer. 

    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. Two- thirds of new chlamydial infections occur among youth aged 15-24 years. It is estimated that 1 in 20 sexually active young women aged14-24 years has chlamydia. (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

    Credentialing: Your Timely Response for Additional Information Is Needed

    As you may know, federal policies require that we keep our Provider Directory as up to date as possible, so plan members have the most accurate information needed to make health care choices. When we receive credentialing applications or requests for updates that are incomplete, we depend on your timely response to our queries for additional information to ensure the most efficient processing. 
    In line with industry standards, we would like to remind all provider offices of our policy regarding requests for additional information originating with our Credentialing department or Provider Data Integrity team.

    • All requests are processed in the order received. We strive to do an initial review of every data request/application within 14 business days of receipt.
    • If additional information is required after initial review, an email will be sent to the email address listed on the request/application.
    • If no response is received after 5 business days, another email will be sent with the original request and a reminder that the data change/application is on hold.
    • If no response Is received after an additional 5 business days, a final reminder will be sent to the listed email address, indicating the request will be canceled if no answer is received within the next 10 business days.
    • If no answer is received in the next 10 business days, the request will be canceled and the contact informed. 

    Reminding Our Members to Get Their Flu Shots

    This year, it is especially important for our members to stay as healthy as possible through the upcoming flu season. Please help us remind them to get their flu shots, if appropriate. Learn about the US Family Health Plan's flu shot benefit and about the Generations Advantage Plan's flu shot benefit!

    New Step Therapy Requirements for Part B Drugs

    Effective January 1, 2022, Martin’s Point Health Care is implementing Step Therapy for some classes of Part B drugs. This Biosimilars-first policy encourages the prescribing of clinically appropriate and lower-cost products. 
    Prior authorization will be required for non-preferred drugs only. An exception process will exist for specific circumstances warranting the use of a non-preferred product. This process will not apply to members who are actively receiving treatment with a non-preferred agent. 

    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.

    “Hold Harmless” Guidelines for Martin’s Point Health Plans

    Covered services: Generations Advantage and/or US Family Health Plan—Network providers have contractually agreed that, except for the collection of copayments, coinsurance, deductibles, payments for noncovered services, or payments for covered services provided after their agreement is terminated, in no event shall they bill, charge, collect a deposit from, or seek any recourse against any member or person acting on a member's behalf for covered services.

    Noncovered services:
    Generations Advantage—Members of our Generations Advantage plan can’t be billed for a noncovered service unless proper notice has been provided in advance. For more information, download our Generations Advantage Acknowledgement and Financial Responsibility Policy.

    US Family Health Plan—Contracted providers must obtain a signed Acknowledgement of Financial Responsibility Statement from the member in order to bill or collect for noncovered surgeries or TRICARE®-excluded services. General waiver forms signed at time of admission are not sufficient per TRICARE regulations. The waiver must be specific to the date of service and include the CPT code and the charge for the service.

    For more detailed information about our “Hold Harmless” policy—including procedures and forms for charging members for noncovered services with specific provisions determined by CMS and TRICARE®, visit

    Just for Kids: 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.

    Just for Kids: Are Your Pediatric Patients Protected against the Flu?

    The CDC recommends that those 6 months of age and older get the flu vaccine by the end of October each year. The best way to prevent flu in your patient and their families is with a flu vaccine. The CDC notes children younger than 5 years of age, especially those under the age of 2, are at a high risk of serious flu-related complications.

    The annual flu vaccine is part of the Childhood Immunization Status (CIS) measure that is used to assess the quality of care our youngest beneficiaries receive. CIS is a quality measure of the percentage of children 2 years of age who have received recommended vaccines by their second birthday. Please contact the health plan if you would like a comprehensive list.


    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

    It is very important that you follow all plan requirements and review all authorization policy changes for the upcoming year to ensure successful claims processing.  Authorization requests missing required information may result in claims being denied in whole or in part. In this event, the member cannot be billed for those denied services.

    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 our online portal or e-mail)
    • Review their credentialing file by scheduling an appointment (via e-mail)

    More information is available at
    Providers may contact us at:
    Email: [email protected]
    Phone: 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