The Point Issue 2 2020

The Point A Newsletter for Martin's Point Health Care Network Providers

provider wearing a facemask

We appreciate you.

As providers of frontline health care ourselves, all of us at Martin’s Point deeply appreciate the courage and dedication of our network providers as you care for our health plan members and ALL your patients during these extraordinary times.
Our goal is to allow you to focus efforts on patient care for the communities we mutually serve and we’re committed to helping you stay up to date with the evolving health plan information you need during this challenging outbreak.
Thank you for all you are doing to keep our members and our community as healthy as possible. Stay safe out there!
Below you’ll find a link to helpful FAQ document with administrative guidance. Our phone lines remain open to respond to any additional questions you may have regarding billing guidelines, testing, and benefit changes implemented during this time. Please contact our Provider Inquiry team at 888-732-7364 if you need further assistance.

COVID-19 Provider FAQs

Telehealth Billing Guidance

Generations Advantage:

In accordance with CMS guidance, “When billing professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), bill with:

  • Place of Service (POS) equal to what it would have been had the service been furnished in-person
  • Modifier 95, indicating that the service rendered was actually performed via telehealth”
Additional references:
  • Medicare Claims Processing Manual Chapter 12
  • CMS Covered Telehealth Services
  • CMS Telehealth FAQ

US Family Health Plan:

TRICARE® does not follow CMS guidance for Telemedicine services.
For synchronous telemedicine services:

  • Bill using CPT or HCPCS codes with a GT modifier for the distant site and Q3014 for the originating site to distinguish telemedicine services.
  • Use Place of Service “02” in conjunction with the GT modifier.
For asynchronous telemedicine services:
  • Bill using CPT or HCPCS codes with a GQ modifier
  • Use Place of Service “02.”
Note: You may indicate "Signature not required–distance telemedicine site" in the required patient signature field on the claim form.
Additional references:
  • TRICARE Policy Manual Chapter 7 section 22.1 provides additional billing and coverage requirements.

Hypertension: Obtaining Accurate BP Readings and Supporting Patients

Obtaining accurate blood pressure (BP) readings in the office can be challenging. Improper technique and “white coat syndrome” result in unusable data and wasted time for staff. Some simple suggestions for obtaining accurate BP readings are listed below:

Prepare the patient

  • Ask the patient to empty their bladder, if needed
  • Confirm the patient has not had nicotine, caffeine, alcohol, or vigorous exercise in the previous hour
  • Position the patient comfortably with legs uncrossed in a chair with back and arm support
  • Place the cuff on a bare arm, 1” above the antecubital fossa with the midline of the bladder over the brachial artery
  • Support the arm so the cuff is at the level of the mid-sternum
  • Ask the patient to refrain from speaking or moving while the cuff is being inflated and deflated

Employ the best practices for blood pressure measurement

  • Wait 5 minutes after applying the cuff before taking the initial reading.
  • Wait 5 minutes and recheck if the initial reading is elevated: document the second reading
  • Size matters—confirm your office has cuffs that will fit all of your patients
  • Consider impact of terminal digit preference, random error, and bias when recording values
  • Advise patients to avoid wrist and finger monitors for home readings

Key messages for patients

Varying treatment targets for hypertension proposed by different professional groups may create questions for both clinicians and patients. One recommendation, however, is clear across all guidelines for hypertension management—patients should be advised to make lifestyle changes aimed at controlling blood pressure and reducing risk:
  • Hypertension is a chronic condition that requires both medications and lifestyle changes to control
  • Reducing weight to normal BMI range may reduce SBP by 5-20 mmHg/kg
  • Regular aerobic exercise such as brisk walking for at least 40 minutes most days of the week may reduce SBP by 4-9 mmHg
  • Alcohol in moderation—no more than one drink daily for women and two drinks daily for men—may reduce SBP by 2-4 mmHg
  • Consuming no more than 2,400 mg of sodium daily may reduce SBP by 1-2 mmHg
  • A diet rich in vegetables, fruits, whole grains, lowfat dairy, nuts, legumes, and limited sweets and red meat may reduce SBP by 8-14 mmHg
  • Stop smoking


James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel embers Appointed to the Eighth Joint National Committee. JAMA.  2014; 311(5):507-520. doi:10.1001/jama.2013.284427  Available at:

Oza R & Garcellano M. Nonpharmacologic Management of Hypertension: What Works? Am Fam Physician. 2015; 91(11):772-776. Available at:

National Center for Complementary and Integrative Health

Patient Sources

American Heart Association

Center for Disease Control and Prevention


Billing for Patients Covered by US Family Health Plan AND Medicare

Do you have patients who are beneficiaries of both the US Family Health Plan and Medicare? It’s important to understand that, if the US Family Health Plan is billed improperly, your patient may be subject to disenrollment from their US Family Health Plan.

Please note these important rules regarding how to correctly bill for services:

  • Medicare cannot be billed for services which are covered by the US Family Health Plan.
  • Beneficiaries who have coverage under both the US Family Health Plan and Medicare may only use Medicare benefits for services that are NOT COVERED by the US Family Health Plan, such as chiropractic care.
  • Beneficiaries filing Medicare claims (or who have Medicare claims filed on their behalf) for services covered under the US Family Health Plan (TRICARE Prime®) are in violation of the conditions of participation for the US Family Health Plan and are subject to disenrollment.

If you have questions about these rules, please contact our Provider Inquiry team at 1-888-732-7364. 

Update Your Info Online with Provider DataPoint

CMS requires us to regularly contact our network providers to confirm our directory information is up to date. We kindly request that you provide us thirty (30) days advance notice of any changes to your provider/practice information when possible.

Provider DataPoint is our web-based provider data management tool that helps us maintain accurate provider directories and perform efficient claim processing. Using this tool is an easy way to keep all your practice/provider data current 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.

Patients Seeking Imaging for Uncomplicated Low Back Pain?

Remember to Discuss Potential Risks

Most providers are aware that imaging studies are overused when evaluating uncomplicated low back pain. However, many still order the tests because patients request them. Ironically, rather than having their minds set at ease, patients with imaging results showing degenerative changes—commonly found in asymptomatic individuals—frequently misinterpret the results, leading to fear, avoidance of activity, and low expectations of recovery. Even worse, misinterpretation of results by clinicians may result in unhelpful advice, needless downstream testing, or invasive intervention.

We encourage clinicians to take the time to discuss the risks and benefits of imaging with their patients. A short conversation about the risks of radiation, expected time frames for recovery, and recommended treatments can go a long way in helping inform shared treatment decisions.

Highlights from the American College of Physicians clinical practice guideline of noninvasive treatments for acute, subacute, and chronic low back pain state that:

  • Acute back pain is defined as lasting fewer than four weeks. Subacute back pain lasts four to 12 weeks.
  • Most patients with acute back pain have self-limited episodes that resolve on their own.
  • Symptoms usually improve within the first month regardless of treatment.
  • Clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence).
  • If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)


Erika D. Sears, Erika, Tanner J. Caverly, Jeffrey T. Kullgren, Angela Fagerlin, Brian Zikmund-Fisher, Brian, Katherine Prenovost, Eve A. Kerr. “Less is more: clinicians’ perceptions of barriers to avoiding inappropriate imaging for lowback pain—knowing is not enough” JAMA Internal Medicine, 176. no. 12 (2016) 1866-1867. Accessed August 07, 2017. doi:10.1001/jamainternmed.2016.6364

Waleed Brinjikji, Patrick H. Luetmer, Bryan Comstock, Brian W. Bresnahan, L.E. Chen, Richard A. Deyo, … Jeffrey G. Jarvik, (2015). “Systematic literature review of imaging features of spinal degeneration in asymptomatic populations.” AJNR. American Journal of Neuroradiology, 36, no. 4 (2015): 811–816. Accessed August 7, 2017. doi: 10.3174/ajnr.A4173

Darlow, Ben, Bruce B. Forster, Kieran Osullivan, and Peter Osullivan. "It is time to stop causing harm with inappropriate imaging for low back pain." British Journal of Sports Medicine 51, no. 5 (2016): 414-15. Accessed August 7, 2017. doi:10.1136/bjsports-2016-096741.

Qaseem, Amir, Timothy J. Wilt, Robert M. McLean, and Mary Ann Forciea. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of Internal Medicine 166, no. 7 (2017): 514-30. Accessed August 7, 2017. doi:10.7326/p17-9032.

Equian Rebranding to Optum

Optum has acquired Equian, the claims auditing vendor used by Martin’s Point. All documentation will be rebranded from Equian to Optum effective this summer. There will be no changes to existing policies or procedures to any Equian audit programs. This is a name change only.


Digital Authorization Management Coming Soon!

Martin’s Point is pleased to announce the upcoming launch of TruCare ProAuth through our partnership with Casenet. TruCare ProAuth is an authorization management tool that allows you to submit digital authorization requests using an easy, online process and receive real-time responses and updates.

TruCare ProAuth software is intuitive and interactive, guiding you through the submission process. Time-saving features include:

  • Electronic submissions of authorization requests and supporting clinical documentation
  • Real-time status updates of submitted requests
  • Authorization pre-screening—instant notification if an authorization is not required or a duplicate authorization exists

Effective August 13, 2020, all providers who have access to the Martin’s Point Provider Portal will be able to enter authorization requests through ProAuth for Generations Advantage and/or US Family Health Plan members.

  • If your organization does not currently have a local administrator for the Martin’s Point Provider Portal but would like to have access to ProAuth, please follow this link to register for access:

Have questions about requesting authorizations through ProAuth?
Training will be available in the summer through the Martin’s Point Provider Portal.


CMS Releases New Information regarding Provider Directories

To support health plans and hospital systems, CMS released information in January to help improve the accuracy of provider directories. Providers may now use the National Plan and Provider Enumeration System (NNPES) to certify their National Provider Identifier (NPI) data. Please see below for the CMS communication released earlier this year. If you have questions, please contact Scott Gullatt, Manager, Network Operations at [email protected].

REMINDER: We recommend that our network providers submit real-time updates to your NPI-related information using our web-based provider data management tool—Provider DataPoint. See more information about using Provider DataPoint above.


Credentialing Corner

Martin’s Point Health Care requires all providers who deliver care to our health plan members on a regular basis to be credentialed. Any provider who will be joining your practice and seeing Martin’s Point health plan members by appointment must go through the credentialing process as part of our commitment to providing the highest-quality care to our members. To ensure an efficient credentialing process, we use the Center for Affordable Quality Healthcare (CAQH) database as an initial source for information verification.

Failure to ensure the information contained in the provider’s CAQH Provider Profile is accurate and up-to-date will result in delays in processing the application.

Failure to ensure the information contained in the provider’s CAQH Provider Profile is accurate and up-to-date will result in delays in processing the application. Please review your provider’s CAQH Provider Profile to make sure the items below are up to date:

  • Attestation is current.
  • Martin’s Point Health Care is authorized to view the provider record.
  • Practice setting is “Inpatient/Outpatient or Outpatient only.” If provider is inpatient only, credentialing is not required.
  • License information is current for state listed on application. Locum Tenens licenses are not sufficient.
  • Education shows the degree(s) listed on application. Foreign degrees must be equivalent.
  • Training section must include training in specific specialty listed on application.
  • Hospital admitting information is current, if applicable.
  • Specialty information shows board certification in specialty listed on application:
    • NPs and PAs must be currently certified;
    • MDs, Dos, and DPMs can be pursuing certification, but must include anticipated exam date;
    • AuDs, ODs, and DCs do not require certification;
    • Providers who completed training prior to 1996 do not require certification (MD, DO, DPM only).
  • Practice location/TIN listed on application must show in practice location section, with corresponding Tax Identification number. Provider must practice at listed location on a regular basis, not covering.

Remember, our efforts to complete the credentialing process within 90 days cannot start until the application meets all the above requirements, so making sure the CAQH profile is complete and up-to date makes a big difference in our ability to process the application in a timely manner.

Next time in the Credentialing Corner: Which type of providers require credentialing… and which don’t. 


Quality Counts for Kids

US Family Health Plan Population-Based Incentive Payments Tied to NCQA Guidelines

Ensuring that our kids are receiving great care is of utmost importance to us. As part of our quality program, Martin’s Point uses standards/guidelines developed by the National Committee on Quality Assurance (NCQA) to measure the quality of care our network providers are delivering to our youngest health plan members. The results of these measures (tabulated annually) are considered when developing the US Family Health Plan Population-Based Incentive Payments we make to providers. The services we measure as part of this assessment are listed below.

Well-Child Visits in the First 15 Months of Life (W15)

  • A count of the number of well-child visits that occur on or before the child turns 15 months of age.

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)

  • A count of children from 3 through 6 years of age who have one or more well-child visit(s) during the past year.

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

  • A count of children from 3 through 17 years of age who have had an outpatient visit in the past year and the following are assessed.
    • BMI—Documentation of a height, weight, and distinct BMI percentile (BMI ranges and thresholds are not acceptable)
    • Nutrition—Documentation of nutrition being addressed (e.g., discussion of behaviors, referrals for nutrition education, providing educational materials, anticipatory guidance, or counseling for weight or obesity)
    • Physical Activity—Documentation of physical activity being addressed (e.g., discussion of behaviors, referrals for physical activity, providing educational materials, anticipatory guidance, or counseling for weight or obesity)

Adolescent Well-Care Visits (AWC)

  • A count of adolescents from 12 through 21 years of age who have at least one comprehensive well-care visit during the past year.