The Point Issue 1 2020

HEDIS Medical Records Requests

Martin's Point will be faxing HEDIS-related medical record requests to network providers from January through early May 2020. We ask for your support in responding to the request as quickly as possible to allow a timely audit by our reviewers.

We will include a phone number for you to use should you have any questions and a secure fax number and physical mailing address to expedite delivery of your records to Martin's Point.

The HEDIS fax number is 207-828-7853 and is only monitored January 1 to May 9.

A reminder that at no time should medical records be faxed to the Provider Inquiry department.

Thank you for your assistance with this effort and for the excellent care you give our health plan members.

New CMS “Important Message” Model Notice Required for Hospitals as of 4/1/20!

Effective April 1, 2020, hospitals will be required to use the revised “Important Message (IM)” form (new form number CMS-10065), although you may begin use earlier. Hospitals must provide the IM form to all Medicare beneficiaries (Original Medicare and Medicare Advantage enrollees) because the form contains the beneficiary’s hospital discharge appeal rights.

A copy of the new version of the form is available on the CMS website via

REMINDER: With the exception of the HINN 3 and HINN 10, Hospital Issued Notices of Noncoverage are not permitted for use with Medicare Advantage beneficiaries. Copies of HINN notices and instructions can be found at

Claims Appeal vs. Claims Dispute

Have a claims issue? Know when to submit an “appeal” or a “dispute”!

Generations Advantage:

  • For participating providers: You do not have appeal rights. You will need to follow the DISPUTE process if you disagree with how your claim was processed. If this is an authorization denial, please submit your dispute with an Authorization Dispute form. If this is not related to an authorization denial, please submit your dispute with a Claim Dispute form.
All of these Generations Advantage forms are available on our website:
Waiver of Liability Form
Generations Advantage Authorization Dispute Form
Claim Dispute Form

US Family Health Plan:

  • APPEALS: Only member liability can be appealed once a claim has been processed. There are no other appeal rights available. The provider must submit a signed Authorization to Disclose Information form if appealing on the member’s behalf.
  • DISPUTES: If disagreeing with anything other than member liability, all providers will follow the claim dispute process.
All of these USFHP forms are available on our website:
US Family Health Plan Authorization to Disclose Form
Claim Dispute Form 

If you have any questions, please contact Provider Inquiry: 1-888-732-7364 or visit our website at

Comprehensive Visit Program Continues in 2020

Incentive for Improving Quality and Medical Documentation through Annual Comprehensive Health Assessments

We are pleased to announce that we will continue our Comprehensive Visit Program for 2020. 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.

Thanks for the Part You Play in Our 5-Star Rating

Martin’s Point Generations Advantage has once again earned a 5-Star quality rating from Medicare, this time for our 2020 Select (LPPO) plan. Earning Medicare’s highest rating is not something a health plan can do on its own and we want to thank you for the important contributions you make to that achievement.

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. 

Martin’s Point Expands Unique Care Management Program

To better serve our Generations Advantage plan members with multiple chronic conditions, in 2017 we launched the Martin’s Point Comprehensive Care Program (CCP). A replication of an evidence-based program developed by Pennsylvania-based Health Quality Partners, the CCP focuses on advanced preventive care management for members with COPD, heart disease and/or diabetes, and on at least seven medications. 

Currently serving over 400 members with Martin’s Point PCPs, we are expanding the program to include Generations Advantage members with network PCPs in the greater Portland and Brunswick areas in Maine.

What Makes the Comprehensive Care Program Unique?
With a focus on advanced prevention, the CCP is unique in that it is a longitudinal program connecting an experienced, community-based RN with the member across all care continuum settings to proactively monitor and address the changing needs that come with multiple chronic conditions. 

The CCP nurse works with the member, their PCP and specialists, and care management teams to assess medical and psychosocial needs, establish patient-centered goals, bridge gaps in care, and coordinate needed resources to support those goals and foster the highest-possible level of patient independence

To learn more, contact the CCP Enrollment Coordinator, Jess Dufour at [email protected] or by calling 207-828-2456.

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: If you have any questions, please see the instructions on our website or speak to a Provider Representative.

IMPORTANT: Remit Process Change as of 4/1/2020

Although we had previously communicated an effective date of April 1, 2020, we wanted to give additional time due to the COVID-19 crisis.  The new effective date is May 1, 2020.

Martin’s Point Health Care is going paperless effective April 1, 2020.

As of this date, we will no longer mail hard copy remittances. These documents will only be available electronically. 

Martin’s Point is pleased to offer three Electronic Data Interchange (EDI) options so you can submit claims and receive your remits for Martin’s Point US Family Health Plan and Martin’s Point Generations Advantage members electronically. 

Each of these vendors offers excellent customer service and will work with you directly to help you get set up. 

Change Healthcare: 1-800-845-6592, Martin’s Point Payor ID: 53275 

Office Ally: 1-866-575-4120, Martin’s Point Payor ID: MPHC1 

Relay Health: New users call 1-866-735-2963. Current users call 1-800-527-8133 to add Martin’s Point Payor ID: MPHC2 

If you are already working with a vendor for your electronic claims, please contact your vendor directly. 

Also, please note, remits can now be viewed and printed directly from our Provider Portal. If you are not registered for the Provider Portal, click here to learn more about registering. If you are already registered, click here for instructions on how to access remittance documents. 

Questions? Call our Provider Inquiry Department at 1-888-732-7364.

IMPORTANT: Service Location Requirement for All HCFA 1500 Forms

Effective 4/1/2020, Martin’s Point Health Care will require that providers 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 Medicare. If these boxes are not completed, the claim will be denied and sent back to the provider for correction. 

If you have questions concerning this change to claims or payment processes, please contact Martin’s Point Provider Inquiry at 1-888-732-7364.

Tips for Getting Prior Authorization for US Family Health Plan Medications

Our prior authorization team is committed to meeting our patients’ prescription drug needs in a timely fashion. We administer pharmacy benefits as outlined by the Department of Defense, and we are required follow their criteria. These tips can help you meet requests promptly: 

Use the right form 

The Department of Defense requires us to use their approved forms. We cannot partner with third-party electronic services, such as CoverMyMeds. If a request is made through a third-party service, it will not reach us and will result in delays getting your patients the medications they need. In addition, third-party services may not have current forms on hand, and if they use an old form, that too, can cause delay. Find the right forms on our website at:

Include documentation 

All requests require clinical documentation. When we get a request without chart notes, for example, we have to follow up with your office staff, which takes additional time and can delay a decision. 

We have 10 days from receipt of request to make a determination. We will send the decision by mail, or by fax if requested. We will also inform the pharmacy know if approval has been made. 

We’re here to help

If you have questions on authorization or process, please call the Provider Inquiry Department at 1-888-732-7364

Just for Kids

Pediatric Behavioral Health Care Management

Martin’s Point Pediatric Care Management Program

One in six children aged 6-17 in the US experience a mental health disorder each year.¹ The Martin’s Point Pediatric Care Management program is offered at no cost and designed to support best-practice care for your young patients. The care managers are social workers and nurses with behavioral health training and expertise.

Initial Outreach: When a care manager first reaches out to your patient, they:

  • Complete a phone intake to assess the family’s and child’s needs
  • Collaborate with the family and care team to design a personalized care plan

Services: Our care managers can assist the family/child in the following ways:

  • Develop questions and prepare for their visits
  • Listen to concerns
  • Find local services and supports
  • Provide additional information regarding their conditions
  • Assist in finding appropriate in-network providers
  • Facilitate medication review and reconciliation with our health plan pharmacy

Conduct targeted outreach to families of children under 18 with two or more dispensing events of the same or different antipsychotic prescription in the past year.

To contact a Martin’s Point pediatric care manager, please call 1-877-659-2403.

¹ Numbers

Annual Quality Monitoring

Martin’s Point monitors the quality of our pediatric members’ behavioral health in a number of ways. We annually monitor the following by claims submission:

  • Metabolic monitoring of children and adolescents ages 1 to 17 who have had two or more antipsychotic prescriptions. Did the patient receive annual blood glucose and LDL-C testing?
  • Follow-up for children ages 6 to 12 years of age who are prescribed ADHD medication:
    • Were follow-up visits made within 30 days of the first prescription?
    • For those who remain on medication for at least 210 days, were at least two follow-up visits made in the 2 to 9 months after the first prescription?
  • How many youth ages 1 to 17 years of age are on antipsychotic medications?

Immunizations for Adolescents

About 80% of people will get an HPV infection in their lifetime. Recommending HPV vaccination for all 11–12-year-olds can protect them before they would typically be exposed. CDC recommends two doses of HPV vaccine for all adolescents at age 11 or 12 years.

CDC recommends that HPV vaccine be recommended like any other vaccination: “Now that your son is 11, he is due for vaccinations today to help protect him from meningitis, HPV cancers, and whooping cough. Do you have any questions?” Parents will need to be reminded to make another appointment for the second dose before they leave the office.

Childhood Immunization Status

Childhood vaccines protect children from several serious and potentially life-threatening diseases—such as diphtheria, measles, meningitis, polio, tetanus, and whooping cough—at a time in their lives when they are most vulnerable to disease. Approximately 300 children in the US die each year from vaccine-preventable diseases.
Immunizations are essential for disease prevention and are a critical aspect of preventive care for children. Vaccination coverage must be maintained in order to prevent a resurgence of vaccine-preventable diseases.