The Point Issue 4 2019

HEDIS Record Review Is Coming Soon

HEDIS medical record review season is around the corner—January through early May 2020. Martin’s Point will fax record requests early in January. We ask for your support in responding to our requests as quickly as possible to allow for timely audit by our reviewers. The request will include our phone number and an email address for you to use for questions, as well as our secure fax number and physical mailing address to expedite delivery of your records to Martin’s Point. Thank you, in advance, for your assistance and for the excellent care you provide to our health plan members.

Laboratory Authorization Reminder

We would like to remind you that certain laboratory services require authorization. We ask that you submit the appropriate authorization requests in advance of sending your patients for these services. We are seeing an increase in Generations Advantage members being sent for high-cost laboratory tests (e.g., genetic testing) to out-of-network providers without authorization—causing increased member costs and dissatisfaction.  

You can find our authorization forms and guidelines at our Provider Resource Center at

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.

Generations Advantage 2020 Formulary Change: Lorazepam

In response to the Comprehensive Addiction and Recovery Act of 2016 (CARA), CMS implemented new regulations to strengthen their efforts against the opioid epidemic and frequently abused drugs. Per the CMS 2019 Final Call Letter, CMS designated benzodiazepines as frequently abused drugs.

For all Generations Advantage plans, lorazepam will move from Tier 1 to Tier 2 effective January 1, 2020. All other benzodiazepines are currently Tier 2. 

This change is one of the few formulary disruptions for current members going into CY2020. Effective November 1, 2019, providers may begin the formulary Prior Authorization processes for their patients.

2020 Plan Benefit Updates Available Jan 1

Please remember to confirm member benefits at the start of each plan year, as benefits can change annually. Updated 2020 plan year benefits for Martin’s Point Generations Advantage and the Martin’s Point US Family Health Plan will be available through the Provider Portal on 1/1/2020.

Generations Advantage:  We have added and enhanced several benefits for 2020 (see member’s individual plan for potential coverage), including:

  • Comprehensive Dental (coverage for crowns, fillings, dentures and more!)
  • Eyewear
  • OTC Benefits
  • Telehealth
  • Opioid Treatment Services

We will continue offering coverage in 2020 for existing benefits (see member’s individual plan for potential coverage), including:

  • Hearing Aids (through Amplifon)
  • Fitness Reimbursement Benefit
  • Nutrition & Dietary Services
  • Weight Management Programs
  • Acupuncture
  • Smoking Cessation
  • Personal Emergency Response System
  • Fall Prevention
  • Bathroom Safety

Once Again, Martin’s Point Earns a 5-Star Rating from CMS for Medicare Advantage Contract

We are proud to announce our 2020 Martin’s Point Generations Advantage LPPO contract is one of only 20 Medicare Advantage contracts nationwide to earn Medicare’s highest Overall Plan Rating—5 out of 5 Stars! The Centers for Medicare and Medicaid Services (CMS) publish their Star Ratings each year to help seniors compare the quality of Medicare Advantage health plans. Overall ratings are based on nearly 50 measures across categories including customer service, member experience, chronic-condition management, how the plan helps members stay healthy, prescription drug services, and more. Generations Advantage plans are Maine’s most popular Medicare Advantage plans, serving over 50,000 members in Maine and New Hampshire. Our 5-Star plan is open for enrollment all year long throughout Maine and New Hampshire.

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 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 the measure of the percentage of children 2 years of age who have received recommended vaccines by their second birthday. The full list of these vaccines will be documented in the next edition of this newsletter.

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

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

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, social workers, and pharmacists 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.

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 (UM) 

The UM team is committed to ensuring that patients receive appropriate care for their medical conditions. UM decisions are based on criteria designed to meet 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 preauthorization can be found at Utilization Management
UM criteria is 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 on 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 meet 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: 207-828-7870

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.