Martin's Point Policies: Where to Find Them

Provider Policies and Compliance Guidelines

Martin's Point Health Care (MPHC) is a managed care organization that adheres to the Centers for Medicare & Medicaid Services (CMS) and TRICARE guidelines regarding coverage and reimbursement determinations. MPHC has developed policies that establish guidelines for providers to ensure the best possible service for our members.

It is essential that contracted providers understand and follow these policies for compliance and accurate claims processing. For access to all our policies, visit our Provider Manual’s Policies section.

Benefit Policy

The primary goal of MPHC’s Benefit Policy is to ensure that benefits are interpreted correctly and that the claims-submission and payment-processing system accurately aligns with the Member Handbook, Evidence of Coverage documents, regulatory requirements, and industry standard practices.

These policies help ensure that providers and members clearly understand which services are included in the benefit package. For more information, view our Benefit Policies.

Medical Policy

MPHC’s Medical Policies are essential in determining whether services are deemed medically necessary and that clinical care meets the standards set forth by government programs and evidence-based clinical guidelines. The criteria used for determining medical necessity are continually reviewed and updated to reflect the most current medical practices.

Providers can refer to MPHC's Clinical Guidelines for more detailed information on how medical-necessity decisions are made. These guidelines serve as the foundation for utilization management decisions regarding medical procedures or treatments. For more information, view our Medical Policies.

Payment Policy

Payment Policies ensure that services are paid for correctly, in line with MPHC's contracts, regulatory requirements, internal policies, and industry standards. These policies are crucial for providers as they dictate how payments for services are calculated and ensure they are fair, accurate, and timely.

By adhering to the Payment Policies, providers can avoid billing issues or delayed payments. These policies help maintain transparency in the payment process, reducing the likelihood of disputes or misunderstandings regarding claims. For more information, view our Payment Policies.

Questions? We're Here to Help.

Martin’s Point understands that navigating policies and procedures can be complex, so it offers support to its contracted providers through the Provider Inquiry Department.

If there are any questions or if additional clarification is needed regarding policies, providers are encouraged to reach out directly to the support team by calling 1-888-732-7364.

Having a clear understanding of our policies is crucial for providers to ensure they are following the necessary steps in the reimbursement process, medical service requirements, and benefit eligibility. By doing so, providers can streamline their operations and ensure a positive experience for their patients.