Authorizations

New Authorization Requirements for Martin’s Point US Family Health Plan Home Health Services (Eff. 10/1/21)

Effective October 1, 2021, Martin’s Point Health Care will require providers to submit initial and extended prior authorization requests for all US Family Health Plan outpatient home health services. These requests should be submitted using our online authorization request tool. Please see the information below for details: 

• Prior authorization requests must be submitted for services with a 30-day episode of care start date on or after October 1, 2021.  Failure to have an approved authorization for home health 30-day episodes with a start date on or after October 1, 2021 will result in a denial of payment for unauthorized services.
• Home health initial or continued 30-day episodes of care with a start date in September 2021 do not require authorization.
• The start date, not the end date, of the 30-day episode will be used to determine the authorization requirement.
• Requests will be reviewed as a 30-day episode of care. Homebound status and clinical documentation supporting the need for skilled services should be submitted with your request. All related medical records such as clinical assessments, therapy evaluations, progress notes, medication lists, and OASIS summary (plan of care) should be submitted with your request.
• Initial requests should be submitted after the initial assessments are completed. Please use the assessment date as the start of services date in your request.
• This home health authorization requirement applies to US Family Health Plan (TRICARE Prime®) members only and does not apply to Martin’s Point Generations Advantage (Medicare Advantage) members.

Instructions

Prior Authorization

• For prescriptions, please visit our Pharmacy page.
• For mental health/substance abuse services for Generations Advantage Plan members call BHCP at 1-800-708-4532.
• For mental health/substance abuse services for US Family Health Plan members call BHCP at 1-888-812-7335.
• For both Generations Advantage and US Family Health Plan members, prior authorization may be requested by the member's PCP or by the servicing provider/facility.
  • Prior authorization is not required for emergency care.
  • Prior authorization requests should be submitted at least 14 calendar days prior to the date of service or facility admission.
  • If the servicing provider is not part of the Martin’s Point network, we require a letter of medical necessity (including clinical documentation) explaining why the service(s) can only be provided by this specialist.
• Imaging Services: The following changes to authorization requirements for imaging services will be effective for dates of service on or after October 1, 2020.
  • Authorization will no longer be required for :
    • Cardiac ECHO, Cardiac Nuclear Stress test and Ultrasound
  • Martin’s Point will assume managing authorization for:
    • Cardiac CT, Cardiac MRI and Cardiac PET
  • eviCore will continue to manage authorizations for:
    • Advanced imaging (non Cardiac CT, MRI, PET, Nuclear

www.eviCore.com/healthplan/Martins_Point

Retrospective Authorization

Please refer to the Forms and Documents section for more information.

Questions? Read more in the Provider Manual or Contact Us.