Health Management

Care Management Program 

Our free Living Healthy programs are available to all Martin’s Point health plan members. As an extension of your care team, we’ll help make sure your patients are following the treatment plans you recommend, taking the medications you prescribe, and successfully managing the conditions you diagnose and treat. To refer a patient to our program, please call 1-866-800-8833.Martin’s Point offers the following care management activities:

Chronic Care Management: Working with a nurse care manager to better understand their chronic conditions, ensure coordination with community providers, adhere to treatment plans, manage medications, improve self-management skills, and take proactive steps towards feeling better. 
Transitions of Care: Working with a care manager to follow up after transition to home, complete medication reconciliation, provide education, review treatment plans, and coordinate follow-up care with community providers. 
Behavioral Health: Working with a social work care manager to assist with both transitions to home and longer term support, review treatment plans, provide education, manage medications, improve self-management skills, and take proactive steps toward feeling better. 
Maternity: Working with a nurse to provide maternal health care management during and after pregnancy to promote the best opportunity for positive health outcomes.

PREAUTHORIZATION
The US Family Health Plan is built on the relationship between members and their primary care providers(PCPs). The PCP is responsible for coordinating all patient care and making initial referrals for specialty care. Specialist providers are responsible for communicating their findings, plans of care, and progress back to the PCP. For certain inpatient and outpatient services or procedures, providers are required to request a preauthorization review for medical necessity. This review for medical necessity must be conducted prior to the medical procedure or service being rendered. Accordingly, preauthorization requests should be submitted at least two weeks prior to the date of service or facility admissions. Preauthorization is not required for emergency care. Please visit the Authorizations page. 
Here you can fill out your request electronically, and review what services require preauthorization. Preauthorization may be requested by the member’s PCP or by the referral provider/facility. This includes services rendered that require preauthorization, extensions to existing preauthorization’s, and any new services requiring preauthorization. Incomplete preauthorization request forms cannot be processed or approved by Martin’s Point. Providers should complete the online preauthorization form. If you are unable to access the online form please fax your request to 1-207-828-7865. Requests may also be submitted by calling 1-888-339-7982
For authorization of mental health and substance abuse services, please call Behavioral HealthCare Program(BHCP), toll-free, at 1-888-812-7335. Please do not resubmit authorization requests unless directed to do so by Martin’s Point. 

Casual inquiries about benefits or the circumstances under which benefits might be paid under a Martin’s Point plan are not considered to be requests for preauthorization subject to these procedures, nor are requests for approval when preauthorization is not required by the plan as a contingency for receiving coverage of the service. You can now check which services and procedures require preauthorization or update your authorization through our online form. Please visit the Authorizations page. 

Preauthorization Request Categories

  • Prospective Non-urgent: Request for services/procedures that are scheduled in advance and submitted before the treatment is delivered. Most requests fall in this category. Non-urgent determinations are made within 14 calendar days from receipt of request. 
  • Post Service: Requests for services that have already been rendered for which a preauthorization was not obtained. Retrospective determinations are made within 30 calendar days. 
  • Prospective Urgent/Emergent: Request for immediate medical treatment required to prevent death or serious impairment of health or for medical treatment needed for an illness or injury that is not immediately life-threatening but requires professional medical attention and should be treated generally within 24hours to avoid serious risk to the member’s health. These requests could not have been anticipated prior to the submission date. Prospective Urgent determinations are made as soon as possible based on the clinical situation, and, in no event, later than 72hours from receipt of request. Note: Preauthorization requests for services that were ordered by a provider more than two week prior to receipt of the request by Martin’s Point will not be processed as Prospective Urgent. Such requests will be reviewed as Prospective Non-urgent. 
  • For urgent/emergency services delivered after normal business hours, the Martin’s Point Health Management department must be contacted the next business day. Please call 1-866-800-8833 with the member’s name, date of birth, the facility name and contact information, the date of admission, the attending physician, and the admitting diagnosis.

Preauthorization determination letters are sent to the member, specialty physician, and facility (if applicable). We do not provide determination letters for services that do not require preauthorization. If preauthorization for a requested service is denied, the reason for the denial is included in the written notification sent to the member and provider. Upon request, Martin’s Point will furnish the criteria used to make the preauthorization determination. Denials based on medical necessity are made only physicians’ the review process identifies care that is not medically necessary, services will not be covered. Providers, along with the member, make the decision whether to proceed with a service or procedure. Martin’s Point preauthorization determination relates solely to payment by one of our health plans. Authorization denials may be appealed. Providers (if designated by a member as their representative) may appeal an authorization denial by calling 1-888-732-7364.

For Generation Advantage members: eviCore healthcare (eviCore) is an independent, specialty medical benefits-management company that provides select utilization management services for Martin’s Point Health Care. Effective September 18, 2017, eviCore healthcare administers prior authorizations for the services listed below for Generations Advantage plan members with dates of service beginning October 1, 2017. Pursuant to the terms of your Participating Provider Agreement, services performed without authorization may be denied for payment, and you may not seek reimbursement from members. Authorization through eviCore is required for:

  • MRI/MRA
  • CT/CTA
  • PET
  • Ultrasound (non-OB)
  • NCM/MPI (Nuclear Cardiac Imaging)
  • Nuclear Medicine
  • Stress Echocardiograms
  • Cardiac Imaging (MR, PET, CT)

High End Imaging services performed in conjunction with an inpatient stay, 23-hour observation, or emergency room visit are not subject to authorization requirements.

To request an authorization from eviCore for the services listed above: Log onto www.evicore.com/pages/ProviderLogin.Aspx  
Existing prior authorization policies and procedure for all other services remain as currently administered by Martin’s Point Utilization Management staff.

Clinical Guidelines

At Martin’s Point our utilization reviewers adhere to clinical guidelines that are based on scientific evidence published in peer-reviewed medical literature that is recognized by the medical community. This ensures that our members receive consistent, high-quality care while avoiding inappropriate or unnecessary procedures, services, and expense. There are no incentives (financial or other) to deny care. Utilization reviewer decisions are based only on appropriateness of care and existence of coverage. For the latest list of clinical guidelines that Martin’s Point adheres to, please visit the Health Management page in the Resources section.

These guidelines are reviewed annually by the Martin’s Point Health Plan Clinical Quality Management Committee (HPCQMC). Guidelines, processes, and updates are also communicated to providers regularly through our Provider Manual and newsletter, The Point. If you have questions or would like a paper copy of these guidelines, please call 1-866-800-8833.

Preventive Care Benefits
Preventive care benefits are designed to keep patients healthy and identify health problems in the early stages. Martin’s Point covers many preventive services at no cost to the member to support early detection of disease or disease precursors in apparently well individuals. Eligible preventive care services vary by health plan, but most are based on recommendations from the US Preventive Services Task Force and/or other federal government or independent agencies responsible for the development and monitoring of various US preventive care guidelines. Preventive care services are covered in accordance with the requirements set forth in the Patient Protection and Affordable Care Act. For a list of covered preventive services, please visit:
Generations Advantage 
US Family Health Plan 

Behavioral Health

Martin’s Point has partnered with the Maine Medical Center Physician-Hospital Organization and its Behavioral HealthCare Program (BHCP) to provide integrated behavioral health services to our members. Our goal is to connect patients with behavioral health resources that can help make the important connections between their emotional and physical well-being. The BHCP is available to members for triage and referral 24 hours a day, seven days a week, through a toll-free telephone line:
US Family Health Plan: 1-888-812-7335
Generations Advantage: 1-800-708-4532

The BHCP is committed to:
• A case management focus
• Utilization of criteria for review in a consistent manner
• Clinical multidisciplinary approach to care management
• 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. The BHCP also documents concerns, complaints, and appeals.

BHCP maintains its own network of contracted facilities and behavioral 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 preauthorization for all services. Clinical criteria are used to determine medical necessity of behavioral health services.

It is the policy of the BHCP to address the individual needs of members. To that end, the 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 behavioral health services, providers may call 1-800-538-9698.

Health Management Communications and Resources

24/7 Nurse Advice Line
Health Plan members enjoy 24/7 access to trained nurses who can answer their health questions. This service is provided by SironaHealth in partnership with Martin’s Point. Members can call anytime with questions about symptoms, injuries, or illness. US Family Health Plan members can call 1-800-574-8494. Generations Advantage members can call 1-800-530-1021.

Healthwise Knowledgebase
Healthwise Knowledgebase is an online resource that offers comprehensive health information to help our members make decisions about their health. Providers and members can access this resource here