Authorizations

For certain services and procedures, providers are required to request a preauthorization review for medical necessity. Preauthorization requests should be submitted at least 14 calendar days prior to the date of service or facility admission. Preauthorization is not required for emergency care.

Online Authorization Request

If you are unable to access our online form, please call our Health Management Department at (888) 339-7982.  Any other questions can be directed to our Provider Inquiry Department at (888)-732-7364.

In order to view authorization requirements you must login to the Benefits and Eligibility Tool found on the Benefits and Eligibility page.

Preauthorization Instructions

For both Generations Advantage and US Family Health Plan members, preauthorization may be requested online by the member's PCP or by the servicing provider/facility. Preauthorization is not required for emergency care. Preauthorization 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.

For authorization of mental health/substance abuse services call BHCP at 1-888-812-7335.
 For drug preauthorizations, please visit our Pharmacy page. For outpatient therapy (PT, OT, ST, SLP), please submit your online authorization request using the Therapy section. 

Retrospective Authorization Instructions

US Family Health Plan: We will review retrospective authorization requests for all qualified care, before or after claim submission. Both participating and non-participating providers may submit online authorization requests. 

Generations Advantage: We will review retrospective authorization requests only under the following circumstances:

Urgent/Emergent: When waiting for preauthorization could seriously jeopardize the life or health of the member, or the member’s ability to regain maximum function. Or, would subject the member to severe pain.
Unable to Know: When the provider did not have, and was unable to obtain, the patient’s insurance information pre-service (i.e., unresponsive patient delivered to an emergency room).
Not Enough Time: When the patient requires immediate or very near-term medical services (typically related to a service already being performed). For example, during a procedure, the provider identifies an acute need for hospital admission or, the procedure that evolves into a different/additional procedure which is performed immediately or scheduled for the same day.

Please read the complete definitions of these exception criteria before submitting a retrospective authorization request. If your situation meets one of these criteria, please submit your request with documentation that supports the “Urgent/Emergent,” “Unable to Know” or “Not Enough Time” exception. We will first assess the criteria for coverage and then for medical necessity.

Participating providers seeking retrospective authorization for a Generations Advantage member must file a claim for that service, wait for claim denial, and then submit an Authorization Dispute Form.

Non-participating providers seeking retrospective authorization for a Generations Advantage member must file a claim for that service, wait for claim denial and then initiate the claim appeal process on behalf of the member. We cannot begin the appeal process without a Medicare Appointment of Representative Form.

Check Status of Pre-Authorization Requests (Sign-In Required)

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Not yet registered? Martin's Point offers a web-based portal for providers to check the status of claims, pre-authorizations and member eligibility. To use this tool, you must first obtain a username for the Martin's Point single sign-on system. For more information, please view our Provider Portal Guide.

Provider Manual: Pre-Authorizations
For more information on Martin's Point Health Care pre-authorization policies and procedures, please review that section of the Provider Manual.
Pre-Authorization Contact Information
Questions? Please call 1-888-339-7982.