Utilization Management

We determine coverage decisions, including medical necessity decisions, on:

• Member’s plan and benefits
• Medicare coverage guidelines including National Coverage Determination (NCD) and Local Coverage Determination (LCD) guidelines
• TRICARE Manuals
• Coverage Determination Guidelines, Utilization Review Guidelines
• State and federal requirements
• The contract between us and the plan sponsor
• Milliman Care Guidelines (MCG), medical, and payment policies

For a list of medical items and services that require prior authorization, decision timeframes, and other associated data, please refer to our Prior Authorization Metrics page.

Our employees, contractors, and delegates do not receive financial incentives for issuing non-coverage decisions or denials.  We do not offer incentives for underutilization of care/services or for barriers to care/service.

We do not hire, promote, or terminate employees based on whether they deny benefits. MPHC will apply objective and evidence-based criteria and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. We use tools such as Centers for Medicare and Medicaid (CMS) National and Local Coverage Determinations, TRICARE policy, and third-party resources (such as MCG Care Guidelines and other national guidelines) as well as Martin’s Point Health Care internal medical guidelines to assist us in administering health benefits and determining coverage. 

If you have questions or would like a paper copy of these guidelines, please visit our Clinical Resources page.

A referral is not the same as an authorization request or approval. A referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. All referrals should be documented in the member's medical chart or electronic health record. A referral does not imply or guarantee payment.

US Family Health Plan referrals

The US Family Health Plan is built upon the relationship between the member and the PCP. The PCP is responsible for coordinating all patient care and making initial referrals for specialty care. Specialists, in turn, are responsible for communicating their findings, plans of care, and progress back to the PCP.

Referrals and Authorizations are not needed for some care such as Urgent/Emergent Care, Routine Preventive Services, and Office Based Mental Health.  Benefits can be checked using the provider portal if unsure whether referral is required.

To find out if a provider or facility participates in our network, check our online directory or call 1-888-732-7364.

Generations Advantage Plan referrals

Generations Advantage HMO plan members are required to select a PCP and to obtain referrals in advance from their PCP for most covered services. Self-referrals are only allowed in certain situations. Referral requirements vary by plan. Please view the individual plan documents for complete details. Whenever possible, please refer Generations Advantage members to a participating provider or facility. To find out if a provider or facility participates in our network, check our online directory or call 1-888-732-7364.

Some plans require prior authorizations of select services and procedures through a pre-service clinical coverage review. You can check authorization requirements by code through the provider portal or through our ProAuth tool.

For urgent/concurrent admissions, admitting providers please be sure to notify the Martin's Point Health Management department of all urgent hospital admissions within 24 hours of admission. Failure to notify in a timely manner may result in denial of payment for services provided.

For authorization of mental health/substance abuse services, please call the Behavioral Health Care Program (BHCP) at for the US Family Health Plan at 1-888-812-7335 or for Generations Advantage call 1-800-708-4532. For drug authorizations, visit our Pharmacy Forms and Documents page. For outpatient therapy), please use our Outpatient Therapy Prior Authorization Request Form [PDF] found on the Forms and Document page.

Once we receive the request for prior authorization and the required clinical information, we can begin a clinical review for coverage. We will notify you of the coverage decision within the time frame required by the Centers for Medicare and Medicaid, TRICARE policy, as well as our accrediting body NCQA.

All services requiring prior authorization codes must be accompanied by a prior authorization request prior to rendering the service. Prior authorization requests should be submitted at least 14 calendar days prior to date of service or facility admission. Exceptions are made for emergency services that necessitate immediate procedures. Failure to comply may result in denial or reduction of payment.

For a list of medical items and services that require prior authorization, decision timeframes, and other associated data, please refer to our Prior Authorization Metrics page.

Can't find what you're looking for? All of our provider forms and documents can be found on the Forms and Documents page.

Clinical coverage review

If you submit the medical information needed with the request for prior authorization, your review will go faster. History & physical admission documentation and discharge planning information is required for all Acute and Post acute Admissions.

To assist us in reviewing your request as quickly as possible please:

• Return calls from our utilization review team and/or Medical Director.
• Submit the correct and most specific code available for the services.
• Comply with our request for additional information, including requests for medical records and imaging studies/reports:
• If you receive our request for additional information, please supply the information within 24 hours unless the need for a shorter timeframe was discussed with a Utilization Review Nurse and/or Medical Director.

Martin's Point has partnered with the Maine Medical Center Physician-Hospital Organization and its Behavioral Health Care Program (BHCP) to provide integrated mental health services to our members. Our goal is to connect patients with mental health resources that can help make the important connections between their emotional and physical well-being.

BHCP is committed to:

• A care management focus

• Utilization of criteria for review in a consistent manner 

• Physician decisions made by local practitioners

• Identification and support of a selected network of providers/vendors who demonstrate a shared commitment to high-quality, accessible care that will lead to the highest member satisfaction

When a Martin's Point health plan member inquires about coverage for mental health or substance abuse services, the Member Services team answers questions and refers him or her to the BHCP for authorization of services. BHCP also documents concerns, complaints, and appeals.

BHCP maintains its own network of contracted facilities and mental health specialists, including hospitals, psychiatrists, clinical psychologists, clinical social workers, licensed pastoral care counselors, marriage and family therapy counselors, clinical professional counselors, and other licensed clinicians. These providers and facilities are listed in the Provider Directories on Martin's Point health plan sites. Benefit coverage requires prior authorization for all services. Clinical criteria are used to determine medical necessity of mental health services.

It is the policy of the BHCP to address the individual needs of members. To that end, BHCP provides alternative clinical guidance to decision makers. In some instances, additional factors (e.g., age, comorbidities, complications, treatment progress, etc.) affect a clinical situation and the criteria are overridden to tailor the service to the member. This may occur with specific situations such as psychosocial situations, home environment, or lack of available services.

BHCP is committed to keeping member information confidential. All persons employed by BHCP are responsible and accountable for safeguarding this information in a consistent, thoughtful, and effective manner in accordance with state and federal law and the National Committee for Quality Assurance (NCQA). The BHCP follows all Health Insurance Portability & Accountability Act (HIPAA) regulations and requirements.

For more information about Martin's Point mental health services, providers may call 1-800-538-9698.

Retrospective authorization requests are for services that have already been rendered (or will be imminently) for which prior authorization was not obtained.

A referral is not the same as an authorization request or approval. A referral is the process of sending a patient to another practitioner (ex. specialist) for consultation or a health care service that the referring source believes is necessary but is not prepared or qualified to provide. All referrals should be documented in the member's medical chart or electronic health record. A referral does not imply or guarantee payment.

US Family Health Plan referrals

The US Family Health Plan is built upon the relationship between the member and the PCP. The PCP is responsible for coordinating all patient care and making initial referrals for specialty care. Specialists, in turn, are responsible for communicating their findings, plans of care, and progress back to the PCP.