Clinical Guidelines

Martins Point HealthCare (MPHC) follows CMS and TRICARE guidelines for the majority of coverage and reimbursement determinations. There are several factors that impact whether a service or procedure is covered under a member’s benefit plan. Medical policies and clinical utilization management (UM) guidelines are two resources that help us determine if a procedure is medically necessary. These documents are available to you as a reference when interpreting claim decisions. For more information on our coverage decisions, visit our Provider Manual on Utilization Management.

Medical Policies

Medical policies are used by all plans and lines of business unless Federal or State law—as well as contract language, including definitions and specific contract provisions or exclusions—take precedence over a medical policy. Those provisions will be considered first in determining eligibility for coverage before the medical policy is used to determine medical necessity. Please visit our Forms and Documents search tool to review more policies by category.

Martin's Point Health Care Medical Necessity Criteria

Clinical UM Guidelines

The clinical utilization management (UM) guidelines published on this website are not always used by all plans or lines of business. Clinical UM guidelines are available for adoption to review the medical necessity of services related to the guideline when the Plan performs a utilization review for the subject. Because practice patterns, claims systems and benefit designs vary, a local plan may choose whether to adopt a particular clinical UM guideline.
 
To determine which clinical utilization management guidelines have been adopted by your plan, or to determine if there are other applicable criteria, please reference the listing provided below.

Clinical UM Guidelines adopted by Martin's Point Health Care

Martin's Point Health Care Part B Step Therapy Clinical Guideline

Martin's Point Health Care Step Therapy Drug List

Other Criteria

In addition to the documents Martin's Point Health Care maintains for coverage decisions, we may adopt criteria developed and maintained by other organizations. Note that where we have developed a medical policy that addresses a service also described in one of these other sets of criteria, Martin's Point Health Care’s medical policy supersedes.

• MCG Guidelines
• Medicare Coverage Determination
• Medicare Benefit Policy Manual
• eviCore Imaging Guidelines
• National Comprehensive Cancer Network (NCCN.org)
• Optum Policies (Radiation Oncology and Specialty Pharmacy) - You must be logged in to see this content