The Point. Newsletter for Martin s Point Health Care Network Providers Inside:

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1 F A L L 2015 The Point Newsletter for Martin s Point Health Care Network Providers Inside: Electronic Claims Resources ICD-10 FAQs 2015 Quality Measures Generations Advantage Updates US Family Health Plan Updates

2 Quit the Paper Claims Habit! Are you still submitting paper claims? It s time to break that habit! Electronic claims submission can save you time, money, and headaches. Most practice management software supports electronic claims submission. Explore your system to see if you already have the ability to: Produce more accurate claims Have faster processing and payment times Spend less time correcting and reposting claims Spend less money on postage and paper We offer three Electronic Data Interchange (EDI) options. Please contact them directly to sign up for electronic claims submission and remittance advices. Emdeon Business Services: Call to enroll. Use Martin s Point Payor ID: Office Ally: Call and select option 3 to enroll. Use Martin s Point Payor ID: MPHC1 Electronic Claim Submission Tips Relay Health, a division of McKesson Technologies: New users should call to enroll. Current users should call to Martin s Point Payor ID: MPHC2 2 When submitting a claim for a patient who is also the subscriber: Data should be submitted in Loop 2010BA (subscriber) only using the following fields: Patient Last Name 2010BA NM103 Patient First Name 2010BA NM104 Patient ID # (code qualifier of MI ) 2010BA NM108 Patient ID # 2010BA NM109 Patient Date of Birth 2010BA DMG02 Patient Gender 2010BA DMG03

3 When submitting a claim for a patient who is a dependent of the subscriber: Data should be submitted in Loop 2010BA (subscriber) and Loop 2010CA (patient) using the following fields: Subscriber Last Name 2010BA NM103 Subscriber First Name 2010BA NM104 Subscriber ID # (code qualifier of MI ) 2010BA NM108 Subscriber ID # 2010BA NM109 Subscriber Date of Birth 2010BA DMG02 Subscriber Gender 2010BA DMG03 Patient Last Name 2010CA NM103 Patient First Name 2010CA NM104 Patient Date of Birth 2010CA DMG02 Patient Gender 2010CA DMG03 New! Electronic Remittance Advice (835) Provider Guide We recently added a new tool to our online Provider Resource Center to make it easier for you to understand Martin s Point Generations Advantage and US Family Health Plan remittance advices files. Our Electronic Remittance Advice (835) Provider Guide is a searchable PDF that maps industry-standard adjustment reason codes to the corresponding Martin s Point claims editing rules and remarks on our 835 files. To search for a specific claim adjustment reason code (CARC) or remit advice reason codes (RARC), just click CTRL F and enter the code into the Find box on your screen. Visit Providers/Claims to use this helpful tool! Electronic Claims Adjustment/Reconsideration Requests Did you know that electronic submission is also easier and faster for claim adjustment/reconsideration requests? Here are a few tips: EDI/837 - CMS/HCFA-1500 or UB-04 Claim Loop 2300 CLM05-1: Patient Control Number - Must contain the patient control number from the original claim. Example: CLM*A37YH566*500***11::7*Y*A*Y*Y*C~ CLM05-3: Claim Frequency Code - Must include the number 7 if you want to adjust the original clam. Example: CLM*A37YH566*500***11::7*Y*A*Y*Y*C~ - Must include the number 8 if you want to void the original claim. Example: CLM*A37YH566*500***11::8*Y*A*Y*Y*C~ A new REF segment which contains a REF01 must contain the value F8 and REF02 - Must contain the Martin s Point claim number from the original claim. Example: REF*F8*12345E06789~ REF Payer Claim Control Number 1 S 2300 REF01 Reference Identification Qualifier ID 2-3 R F8 REF02 Claim Original Reference Number AN 1-50 R To adjust a claim, add a new segment: NTE*ADD*Adjusted Claim Reason for Claim Adjustment. Examples: 1. NTE*ADD*Adjusted Claim CPT Code change from to 99284~ 2. NTE*ADD*Adjusted Claim Added 3 new Service Lines and Charges~ 3. NTE*ADD*Adjusted Claim Removed service line~ 4. NTE*ADD*Adjusted Claim Modifier GF added to CPT Code 99284~ To void a claim, add a new segment: NTE*ADD*VOIDED CLAIM. 3

4 4 Requests for claim adjustment may be filed after the original claim has been finalized (paid or denied). When submitting a request for claim adjustment, be sure to include all lines from the original claim which are still correct, not just the new or corrected lines. Please keep in mind that the adjusted claim will replace the original claim in its entirety. All payments on the original claim will be reversed and only those lines included on the adjusted claim will be reviewed for payment. Electronic submission is preferred with the exception of claim adjustments pertaining to COB, EOB, timely filing and medical documentation. To process these requests we must have both a completed Claim Adjustment Form ( For-Providers/Claims) showing the original claim number and a paper copy of your adjusted claim with the corrected and/or additional information. Returned claims that do not include a Martin s Point claim identification number cannot be adjudicated and therefore, are not entered into our claim system. If you wish to resubmit a returned claim, do not submit a request for claim adjustment. Please submit an entirely new claim and do not use the words Corrected, Replacement, or Adjusted anywhere on the claim. Both participating and non-participating providers must file requests for claim adjustment within 120 days from the remittance date. IMPORTANT! Make sure the patient control number and claim number on your adjustment/reconsideration request matches the original claim. We understand that some practice management systems may automatically assign a new patient control number each time you create a claim. However, our system will automatically pend your adjustment/ reconsideration request if the patient control number and/or claim number does not match the original claim. This will cause processing delays. If you must submit paper claims, please avoid these common paper claims submission errors. Missing or invalid member ID numbers: Subscriber/Insured ID numbers end in 00 and dependent ID numbers end in 01, 02, 03, etc. according to the number of dependents. Member ID numbers should contain 11 digits including the two-digit suffix. Samples of our health plan ID cards are shown below. Missing or invalid provider National Provider Indicator (NPI): It is very important for Provider NPI and Billing Provider NPI information to be properly presented. On CMS-1500 claim forms, pay attention to: Box 24J This should be the NPI number of the individual provider rendering the service (i.e., the Type 1 NPI of the specific physician rendering the service). Enter the

5 rendering provider NPI number in the field to the immediate right of the letters NPI. Not in the blank spaces above or below. Box 33A This should be the NPI of the billing entity named in Box 33 (i.e., the Type 2 NPI assigned at a group level to the practice). Type 2 NPI numbers are also known as organizational NPI numbers. In most instances, the number in Box 33A should not be the same as the number in Box 24J. ICD indicator field: On a CMS-1500 form, the ICD indicator field must be completed to identify the ICD-CM code set being reported. Enter either: 9 to indicate the ICD-9 CM diagnosis code set 0 to indicate the ICD-10 CM diagnosis code set Enter the indicator as a single digit between the vertical, dotted lines. Failure to complete this field or incorrectly completing this field will result in claim rejection. Example for dates of service prior to October 1, 2015 billed with ICD-9 CM codes: 9 10 We want to pay your claims as quickly as possible. Please help us do so by filling out your claim forms carefully. Questions? Please visit or call

6 ICD-10 Frequently Asked Questions 1. When should providers use ICD-10 Codes? Dates of service are the key driver of whether to use ICD-9 or ICD-10 codes. For example, if a claim is submitted after 10/1/15 for a date of service prior to 10/1/15, only ICD-9 codes should be reported. For inpatient facility claims, date of service is defined as date of discharge. Claims for dates of service/discharge on and after 10/1/15 must be coded in ICD-10. Claims for dates of service/discharge prior to 10/1/15 must be coded in ICD-9. No claim can contain both ICD-9 and ICD-10 codes. Any claims for dates of service after 10/1/15 that contain ICD-9 codes will be rejected. 2. Will Martin s Point accept ICD-9-coded claims for dates of service after 10/1/15 if we encounter claims processing issues on or after 10/1/15? No. All claims with dates of service/ discharge 10/1/15 and after must use ICD-10 codes. 3. How will Martin s Point communicate ICD-10 related denials? We do not have any specific denial codes for ICD-10. Remittance statement claim denial codes that could be related to ICD-10 are: Martin s Point Claims System Edit Potential Scenario Claim Adjustment Reason Code (CARC) Remittance Adjustment Reason Code (RARC) Edit 525: Diagnosis code is not valid on DOS You used an ICD-10 code to bill a date of service/discharge that occurred prior to 10/1/15. Or, you used an ICD-9 code to bill a date of service/discharge that occurred on or after 10/1/ Payment denied because the diagnosis was invalid for the date(s) of service reported. Not applicable Edit 9150: Missing or invalid diagnosis The ICD-9 or ICD-10 code you submitted on the claim is not valid for the primary diagnosis. 16 Claim/ service lacks information which is needed for adjudication M63 Missing, incomplete, invalid, or other diagnosis 4. Will these codes be reflected on 276/277 files? This transaction is not currently available through Martin s Point. 5. What should I do if our practice is having trouble with our billing software, practice management system, or clearinghouse and we can t submit claims? Please contact your software provider or clearinghouse directly. 6. Has Martin s Point updated its medical and payment policies to include ICD-10 coding? Not applicable. 7. How should providers submit claims for services that span 10/1/15? Outpatient Services: We cannot accept claims containing both ICD-9 and ICD-10 codes. Therefore, services provided prior to 10/1/15 must be billed separately (using ICD-9 codes) from services provided on or after 10/1/15 (using ICD-10 codes). Inpatient Services: Inpatient claims with date of discharge before 10/1/15 must be submitted with ICD-9 codes; those with date of discharge on or after 10/1/15 must 6

7 be submitted with ICD-10 codes, even if the patient was admitted prior to 10/1/15. Do not split inpatient claims by date of service. Inpatient Professional Services: We cannot accept claims containing both ICD-9 and ICD-10 codes. Claims for dates of service/ discharge on and after 10/1/15 must be coded in ICD-10. Claims for dates of service/ discharge prior to 10/1/15 must be coded in ICD-9. Emergency Department (ED)/Observation Services: Bill ICD-9 or 10 codes based on the start date of service. For example, if ED or Observation began on 9/30/15 and extended to 10/1/15 please bill with a 9/30/15 date of service using ICD-9 code(s). If other services occur outside of the observation, those services should be billed based on the date of delivery. This may require a split bill. Anesthesia Services: Bill ICD-9 or 10 codes based on the start date of service. CMS has provided guidance on how to handle claims that span the 10/1/15 transition date. Martin s Point will adhere to this guidance. Please visit Regulations-and-Guidance/Guidance/ Transmittals/2014-Transmittals-Items/ SE1408.htm for more information. 8. If outpatient procedures are submitted on an ICD-10 claim, do you require PCS instead of CPT codes? Outpatient procedures should continue to be billed with CPT or HCPCS codes. 9. Will Martin s Point support dual submission of ICD-9 and ICD-10 diagnosis and procedure codes? No, each claim must contain either all ICD-9 codes or all ICD- 10 codes based on date of service. 10. Will Martin s Point accept 837 batches with both ICD-9 and ICD-10 claims? Yes, provided that ICD-9 and ICD-10 codes are not combined on the same claim. Martin s Point will accept 837 batches with separate ICD-9 and ICD-10 claims. 11. What ICD-10-compatible grouper will Martin s Point use as of 10/1/15? DRG grouper 33 has been updated to support ICD-10 compliance. 12. How long will Martin s Point support ICD- 9 coding for corrected claims/appeals? ICD-9 code support will be based on claim date of service, standard timely-filing limits and appeal timeframes. Participating and nonparticipating providers have 120 calendar days from the date of remittance (for dates of service/discharge prior to 10/1/15 only) to submit a corrected claim or appeal with ICD-9 codes. In the event of an appeal, use the ICD-9 or 10 code based on date of service. 13. Will Martin s Point implement a new appeal process related to ICD-10 code selection and/or DRG classifications used for reimbursement? No, Martin s Point will continue to use its current processes. 14. What restrictions, if any, will Martin s Point place on the acceptance of unspecified codes for ICD-10? Until further notice, Martin s Point will handle unspecified ICD-10 codes in the same manner as we currently handle unspecified ICD-9 codes. 15. If a provider submitting claims billed under the Part B physician fee schedule does not use the most specific ICD-10 diagnosis code but one from the same ICD-10 family or category within a 12 month period after the ICD-10 implementation, will you approve the claim in a similar fashion as the grace period extended by Medicare? Providers are required to submit the most specific and valid diagnosis codes possible, based upon the information that is available to them. Unspecified codes are acceptable when sufficient clinical information about a health condition isn t known or available to assign a more specific code. 16. What is the policy for appealing claims denied due to what is believed to be an invalid or incorrect GEMS or CMS reimbursement mapping? Please refer to 7

8 our Claim Reconsideration Guidelines and Claims Reconsideration Request Form at Claims. 17. Are interim or advance payments an option? No 18. What are your ICD-10 Preauthorization Request Protocols? Use ICD-9 codes for preauthorization requests for service/discharge dates expected to occur prior to 10/1/15 Use ICD-10 codes for preauthorization requests submitted on or after 9/1/15 for service/discharge dates expected to occur on or after 10/1/15. For services/discharges with preauthorizations based on ICD-9 codes expected to occur prior to, but actually spanning, or occurring on or after 10/1/15, resubmit the preauthorization request using ICD-10 codes. To request an authorization extension for services/discharges expected to occur prior to 10/1/15, but actually occuring on or after 10/1/15, submit a new preauthorization request using ICD-10 codes. Please fax completed preauthorization request forms to our secure machine at or call , Mon-Fri, 8 am-4:30 pm. For preauthorization of mental health and substance abuse services, please call Behavioral HealthCare Program (BHCP), toll-free, at Are your preauthorization requirements changing on 10/1/15 due to the transition to ICD-10 codes? Not applicable. All of our preauthorization requirements are based on procedure codes. Authorization requests based on medical necessity will require the correct ICD-10 diagnosis code. 20. Will you allow retrospective authorization requests after 10/1/2015 for dates of service prior to 10/1/2015? If the retrospective authorization request meets the specific criteria outlined in our provider manual ( Provider-Manual/PreAuthorization), it may be submitted using ICD-9 codes. 21. If referrals based on ICD-9 codes span 10/1/15, do you require another referral on 10/1/15 using ICD 10 codes? No. 22. Who is available at Martin s Point to answer ICD-10 provider questions? Provider Inquiry Team: Provider Web site: Network Management Team: Other Information and Resources As with ICD-9, ample resources are available to assist providers with coding and clinical documentation for ICD-10. Official government coding guidelines cover: Diagnosis coding: Medicare/Coding/ICD10/Downloads/2016- ICD-10-CM-Guidelines.pdf Inpatient procedure coding: Downloads/2016-Official-ICD-10-PCS- Coding-Guidelines-.pdf CMS Documentation and Coding Basics for Physicians: General Equivalence Mappings: cms.gov/medicare/coding/icd10/2015-icd- 10-CM-and-GEMs.html ICD-10 National Coverage Determinations: CoverageGenInfo/ICD10.html 8

9 Quality Measures Annually, using surveys and other measurement tools, Martin s Point assesses the quality and safety of the medical programs and care that our members receive. For example, we measure: Chronic Disease and Prevention: We focus on ways to help members with these diseases, and to learn how to prevent disease through screenings and checkups. Coordinating Care: We also have programs that help members and providers work together on plans for returning home after hospital stays and for managing complex health issues. Service Quality: We also measure member and provider satisfaction with our customer service and use this information to make improvements. Like most health plans in the United States, we use the annual Healthcare Effectiveness Data and Information Set (HEDIS *) to measure care and service. We also use the Consumer Assessment of Healthcare Providers and Systems (CAHPS **) survey to measure member satisfaction with their care, their health plan, and their providers. Our CAHPS scores have consistently been in the high 90th percentile for member satisfaction. We also get data from a variety of other surveys and tools. All of this data helps us understand what improvements to focus on. US Family Health Plan 2015 HEDIS Results For the US Family Health Plan, we gather two sets of HEDIS data each year; one for the state of Maine and the other for remaining states where Martin s Point provides services to US Family Health Plan enrollees, including Massachusetts, New Hampshire, New York, Pennsylvania, and Vermont. You ll find out most recent scores in selected categories below. We compare ourselves against the national 90th percentile, the rate for the best-performing health plans in the country. You can see that for most of the measures listed below, the US Family Health Plan meets or exceeds the rates of the best-performing plans in the United States. In those areas below the 90th percentile, ongoing member outreach will occur to promote wellness. Recent Prenatal and Post-Partum Care and Colorectal Cancer Screening HEDIS scores indicate an opportunity to better support our members. Martin s Point will continue to offer a maternity program, which encourages pregnant women to seek early prenatal care and post-partum visits within six weeks of delivery. In addition, education and reminders on preventive services, such as colorectal screening, will be provided to members. 9

10 Martin s Point US Family Health Plan Members To read their story, visit US Family Health Plan HEDIS Scores HEDIS Measure National 90th % Benchmark Commercial HMO/POS US Family Health Plan Maine US Family Health Plan Other States Adult Body Mass Index Assessment (BMI) * Breast Cancer Screening * Controlling High Blood Pressure * Diabetic Hemoglobin A1C Testing Diabetic Annual Eye Exams Colorectal Cancer Screening * Timeliness of Prenatal Care * Post-Partum Care * Colorectal Cancer Screening * *Identified opportunity for improvement 10

11 2015 Generations Advantage HEDIS Results For Generations Advantage, we gather HEDIS data annually in Maine and New Hampshire. You will find our most recent scores in selected categories below. We compare ourselves against the national 90th percentile, the rate for the best-performing health plans in the country. For most of the measures listed below, Generations Advantage plans meet or exceed the rates of the best-performing plans in the United States. In those areas below the 90th percentile, ongoing member outreach will occur to promote wellness. Recent HEDIS scores indicate an opportunity to support our members with COPD (Chronic Obstructive Pulmonary Disease) after they are hospitalized or visit the emergency room with a worsening of their condition. In response, Martin s Point developed and implemented a new COPD medication adherence program to help members control their disease. Additional reminders for breast cancer screening and hemoglobin A1C testing will also be provided to members as appropriate. Behavioral health follow up appointments within seven days will also be a focus for our behavioral health care provider Generations Advantage HEDIS Scores HEDIS Measure 2014 National HMO/POS 90th % Benchmark Medicare 2015 HEDIS Result Controlling Blood Pressure Colorectal Cancer Screening Diabetic Annual Eye Exams Pharmacotherapy Management COPD Exacerbation Corticosteroid Breast Cancer Screening * Diabetes Hemoglobin A1C Testing * Pharmacotherapy Management COPD Exacerbation Bronchodilator Follow Up After Hospitalization From Mental Illness Within Seven Days * * *Identified opportunity for improvement Please HEDIS@martinspoint.org for the entire list of HEDIS scores. *HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). **CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 11

12 Generations Advantage Updates Focus DC (HMO SNP) Diabetes mellitus is a growing problem with an increasingly negative impact on the communities we serve. Recent survey data estimate that 8.3% of the adult population in Maine has been diagnosed with diabetes. In addition, an estimated 3.1% of Maine adults have diabetes but do not know it. Based on these estimates, 11.4% of Maine adults have diabetes. 1 In response, Martin s Point has developed Generations Advantage Focus DC (HMO SNP), a Medicare Advantage Special Needs Plan that provides focused care for people in Cumberland County, Maine who are living with chronic or disabling diabetes mellitus. Focus DC (DC stands for Diabetes Care) augments core primary care services with innovative disease management programs designed to improve patient health outcomes and reduce health care costs. Launching in January 2016, the plan will feature: Coordinated care Smaller patient populations Close partnership between plan, members, and providers Individual care plans Specialized benefits Disease/Case management services Working as an extension of our network primary care teams, Focus DC care managers will help make sure patients understand their chronic condition, follow their recommended treatment plans, and make healthy choices that improve the quality of their lives. For more information, please call Maine CDC, Health Fact Sheet: Diabetes in Maine, August population-health/dcp/documents/factsheet.pdf Retrospective Authorization Request Process Change Please note that we have recently changed our Generations Advantage retrospective authorization request process. Participating providers seeking retrospective authorization for services rendered to a Generations Advantage member must file a claim for that service, wait for claim denial, and then submit a claim adjustment/reconsideration form (www. MartinsPoint.org/For-Providers/Claims). Nonparticipating providers seeking retrospective authorization for services rendered to a Generations Advantage member must file a claim for that service, wait for claim denial, and then initiate the claim appeal process ( Member-Toolkit/Grievances-and-Appeals). We cannot begin the nonparticipating provider appeal process without a signed Waiver of Liability Form ( For-Providers/Preauthorizations). 12 Part D Prescriber Enrollment Requirement On June 1, 2015, the Centers for Medicare & Medicaid Services (CMS) announced that it will delay enforcement of the requirements in 42 CFR (c)(6) until June 1, This rule requires physicians and eligible professionals to be enrolled in or opted out of the Medicare program in order to prescribe a covered Part D drug on or after June 1, This rule also requires Part D sponsors, such as Martin s Point Generations Advantage, and their pharmaceutical benefit managers (PBMs) to verify that a physician or eligible professional is either enrolled in or opted out of the Medicare program. The enrolledin or opted-out status of providers is

13 maintained in the Provider Enrollment, Chain, and Ownership System (PECOS). Beginning June 1, 2016, the prescription drug event (PDE) file layout and edits will be updated to incorporate the use of the PECOS in prescriber identifier editing. Generations Advantage members presenting prescriptions written by prescribers who do not meet either one of these requirements will not be able to fill their prescriptions through our plan, effective June 1, Prescribers of Part D drugs must submit their Medicare enrollment applications, or their opt-out affidavits, to their Part B Medicare Administrative Contractors (MACs) no later than January 1, 2016 to allow the MACs sufficient time to process the requests by the policy start date of June 1, Prescribers may enroll in Medicare in order to be reimbursed for all Medicare-covered services, OR, they may enroll only for the purpose of prescribing Part D drugs. Separate application forms for each purpose, and opt-out affidavit forms, may be completed electronically or on paper. There are no fees to complete either process. A complete description of the rule, instructions to complete the applications or affidavits, links to both paper and electronic documents, and links to a continuously updated enrollment file that identifies providers who are currently in an approved or opt-out status, are available at Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE1434.pdf US Family Health Plan Updates Diabetic Testing Supplies Benefit Change Effective August 5, 2015, the Department of Defense imposed a quantity limit to diabetic testing supplies, limiting coverage to 100 strips per 30-day supply in the Retail Network and 300 strips per 90-day supply at any Martin s Point pharmacy. This change also applies to the Martin s Point US Family Health Plan. If the allotted testing supplies per 90 days are not enough based on your patient s testing regimen, you may submit paperwork for a Quantity Limit Authorization on behalf of your patient. If you have questions, please call our Provider Inquiry Department at Billing Reminder Martin s Point US Family Health Plan is a unique TRICARE Prime option, administered by Martin s Point through a contract with the Department of Defense. Martin s Point US Family Health Plan provider agreements prohibit providers from seeking payment from US Family Health Plan members except for applicable specific cost-sharing amounts and for payments relating to noncovered services, provided the member acknowledges responsibility in writing for the specific noncovered service before it is received. General waiver forms signed at time of admission are not sufficient, per TRICARE regulations. The waiver must be specific to the date of service and include the CPT code and service charge. Practices such as converting unpaid patient accounts to self-pay status after a certain number of days and/or referring unpaid accounts to collections after a certain period are not allowed. Please reach out to us at , rather than to our members, to resolve any claims payment issues. Thank you! 13

14 General Reminders Update Your Info! Please notify Martin s Point immediately of any provider or practice information changes to help us maintain accurate provider directories and timely claim reimbursements. Please also provide Martin s Point with your latest provider panel status so that our members know whether or not your practice is accepting new patients. Visit our provider directory online at Pharmacies to review the information we currently have in our system for your practice or facility. If any information is out of date, please visit Providers/ Update-Your-Info to download our latest provider/practice data change forms. Use the Practice Data Change Form (PDF) to update the information for an entire facility, practice, or group of providers. NOTE: You cannot use this form to add a new location. If you are adding a new practice location that is already contracted, submit a Contract Information Form (PDF). Call to add a new facility (Hospital, Skilled Nursing Facility, Ambulatory Surgical Center, etc.). A new participation agreement and/or credentialing application may be required. Use the Provider Data Change Form (PDF) to update the information for a single provider who is participating with Martin s Point. Completed change forms may be submitted via , fax, or mail: ProviderChanges@MartinsPoint.org Fax: Mail: Martin s Point Health Care Network Management Department PO Box 9746 Portland, ME Use the Right Forms! Please make sure you are using the latest versions of our forms. For example, we recently updated our Provider and Practice Data Change Forms ( Update-Your-Info) and our Credentialing Provider Data Form ( For-Providers/Credentialing). Out-of-date versions of these forms cannot be processed and will be returned. Use the latest versions to speed authorization and claims processing time. Please send completed Provider and Practice Data Change forms to providerchanges@martinspoint.org. Please send completed Credentialing Provider Data Forms to providercred@ martinspoint.org. 14

15 Preauthorization Requirements Did you know that Martin s Point offers a code-level, preauthorization requirement search tool for both our US Family Health Plan and Generations Advantage plans. Providers tell us that they love this tool! 1. Visit 2. Click the US Family Health Plan or Generations Advantage Requirements tab: Preauthorizations For certain services and procedures, providers are required to request a preauthorization review for medical necessity. Preauthorization requests should be submitted at least two weeks prior to the date of service or facility admission. Preauthorization is not required for emergency care. Preauthorization Instructions US Family Health Plan Preauthorization Requirements Generations Advantage Preauthorization Requirements 3. Select the CPT/HCPCs Code List: Preauthorization Instructions US Family Health Plan Preauthorization Requirements Generations Advantage Preauthorization Requirements Generations Advantage 2015 Preauthorization Requirements (PDF) Preauthorization Request Form (PDF) Generations Advantage CPT/HCPCs Code List (PDF) 4. Click CTRL F to search for a specific code within the PDF. This document is updated periodically and is accurate as of the listed date. Please do not download and save this document to your computer as the information may be out of date the next time you need to use it. Always refer to the latest version on our website. Please call if you have any questions. Thank you! 15

16 PO Box 9746 Portland, Maine NONPROFIT ORG US POSTAGE PAID PERMIT #186 PORTLAND, ME Inside Electronic Claims Resources ICD-10 FAQs 2015 Quality Measures Generations Advantage Updates US Family Health Plan Updates Please visit for more information on the topics covered in this newsletter and to review the Martin s Point provider manual. You may also call with any questions or to request paper copies of any of the information on our website.