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G E N E R A T I O N S A D V A N T A G E
Martin’s Point Generations Advantage
An Introduction to Martin’s Point Generations Advantage for Contracted Providers
Introduction
Thank you for joining the
provider network for Martin’s Point
Generations Advantage. We’re proud to
serve our local Medicare benefi ciaries,
and we’re glad to have you as our partner
in providing these services.
The information provided in this booklet
should help answer some frequently
asked questions about our plan. Included
is information about Martin’s Point and
some specifi c information about our
benefi ts, authorization requirements,
and billing guidelines.
Additional information and provider
forms are available online at
martinspoint.org. (Click on “For Network
Providers.”) If you have questions,
feel free to contact us at the numbers
provided on the inside back cover.
About Martin’s Point
Martin’s Point Health Care is a Maine-
based not-for-profi t organization that
provides health care to a range of
different groups, in a variety of ways.
We provide medical care to patients
at our Health Care Centers in Maine
and New Hampshire, and we also offer
several health insurance plans to specifi c
groups, including military benefi ciaries,
employees of self-insured employers, and
Medicare benefi ciaries. Our president
and CEO, David Howes, MD; our board
of directors; and all of the staff here at
Martin’s Point are focused on one thing—
improving the health of the
people we serve.
2
feel free to contact us at the numbers
provided on the inside back cover.
22222
3
About Martin’s Point Generations Advantage
At Martin’s Point, we offer
Medicare Advantage plans to
benefi ciaries in our service area, which
for 2011 includes all counties in Maine. We
are the only not-for-profi t organization
that offers Medicare Advantage in Maine,
and we are the only local company that
offers these services in Maine.
We began offering our Medicare
Advantage plan in 2007 because we
saw a need for a plan that offered great
health benefi ts and great customer
service—but most of all—one that had the
best interests of benefi ciaries in mind.
Our Generations Advantage plans are
HMO- and PPO-style Medicare Advantage
plans that cover Medicare Part A (hospital
insurance) and Medicare Part B (medical
insurance) benefi ts, plus additional
benefi ts. With our plans, members pay
copayments or cost shares for their
hospital stays and offi ce visits. Our plans
also offer an annual cap on out-of-pocket
expenses and include Part D prescription
drug coverage.
Our current provider network includes
approximately 3,000 physicians, facilities,
allied professionals, and ancillary
providers. With your assistance,
we have been able to develop
and offer a program that provides
benefi ciaries with access to a broad
network to meet their health care needs.
Thank you again for your support. We look forward to continued growth and success for Generations Advantage.
44
Billing Guidelines
Martin’s Point Generations Advantage adjudicates all claims at our Portland, Maine,
operations offi ce. Clean claims are paid within 30 days of receipt.
CMS 1500 Field GuidelinesFields Description
1a Martin’s Point Health Care Member ID Number as presented on ID card
2 Patient name as presented on ID card
3–8 Required information per CMS 1500
9 Submit, if applicable
10 Required information per CMS 1500
11 Group numbers are not assigned to Generations Advantage Members
11C Indicate “Generations Advantage”
12–13 “Signature on File” and date
14–16 and 18 If required for the claim, do not use default numerals such as zeros
17, 17a, 17-b Not required for processing
19–20 Not required for processing
21 All ICD-9 codes are required to be reported to the appropriate 4th or 5th digit as applicable
22–23 Not required for processing
24a–24i Valid dates of service MM/DD/YYYY, two (2) digit place of service (no Medicaid codes), valid CPT codes, valid two (2) digit modifi ers, diagnosis pointers e.g., 1–4 only, valid charges, and valid units/days as applicable
24j Not required for processing—Un-shaded fi eld servicing provider NPI
25 Required—Tax ID, Employer Tax ID, or Social Security number
26 Not required for processing
27 Required—yes or no
28–30 Required information per CMS 1500
31 Required—original signature is not required; “Signature on File” recommended with typed supplying provider name and credential
32–33 Required information per CMS 1500
33a National Practitioner Identifi er (NPI)
Please submit claims to:
Martin’s Point Generations Advantage
Claims Department
PO Box 11410
Portland, ME 04104-7410
For claims status, please call
Provider Inquiry at 1-888-732-7364.
5
Authorization Process Summary
Primary Care Physician Referral
HMO members are required to select
a primary care physician (PCP) and to
obtain a referral in advance from their
PCP for most covered services. All
referrals must be properly documented
by the PCP in the member’s chart or
health record. PPO members do not
require referrals. However, they do
require authorization for some in and out
of network services.
Generations Advantage members may
self-refer only for the following services:
• Emergency services (in or out
of network). CMS defi nes an
emergency condition as a medical
condition manifesting itself by acute
symptoms of suffi cient severity
(including severe pain) such that
a prudent layperson, with average
knowledge of health and medicine,
could reasonably expect the absence
of immediate medical attention to
result in:
1) Serious jeopardy to the health of
the individual or, in the case of a
pregnant woman, the health of the
woman or unborn child;
2) Serious impairment to bodily
functions; or
3) Serious dysfunction of any bodily
organ or part.
• Urgent care needed from an out-of-
network provider when temporarily
outside the service area or in-area
care received from an out-of-network
provider when circumstances dictate
network providers are unavailable
or inaccessible. (Note: Follow-up to
urgent care requires PCP referral.)
• Routine women’s health services
including breast exams, mammograms,
Pap smears and pelvic exams (from an
in-network provider).
• Flu shots and pneumonia vaccinations
(from an in-network provider).
• Renal dialysis services for members
temporarily outside the service area.
• Behavioral health services (member
contacts BHCP directly for services).
Note: A referral from the member’s PCP does not imply or guarantee payment by Martin’s Point Generations Advantage.
Authorization Requirements
Some covered services must be
authorized by Generations Advantage
as a condition of payment. Services
requiring authorization that are not
approved will not be covered, except as
specifi ed under Medicare regulations.
The following services require prior
authorization:
• Inpatient hospital admissions
• Skilled nursing facility admissions
• Comprehensive outpatient
rehabilitation facility services
• Pain management clinic and pain
center services
• Wound clinic and wound center
services
In addition, the following treatments and
procedures require prior authorization
by Martin’s Point Generations Advantage
regardless of the setting:
• Services from non-network providers
(for HMO members)
• Blepharoplasty
• Bone growth stimulators (including
implantation)
• Breast reduction/reconstruction
• Chemotherapy infusion
• Cognitive therapy
• Cosmetic or reconstructive surgery
• Durable medical equipment
(Please refer to separate list.)
• Hyperbaric oxygen treatment
• Intradiscal electrothermal annolplasty
• Morbid obesity-related services
• Neuropsychological testing
• Non-emergency transportation
• Oral surgery
• Orthognatic surgery
• Orthotripsy
• Oxygen for home use
• Pain control pumps (including
implantation)
• Psychological/psychiatric services
relating to acquired brain injury
• Radiation Therapy
• Rhizotomy
• Spinal cord stimulators
(including implantation)
• Strabismus surgery
• Transplants
6
77
Authorization Process Components
• Requests may be submitted to
Generations Advantage by phone
or by fax.
• Authorizations can be requested
by calling Martin’s Point Health
Management Department at
1-888-339-7982 or 207-253-6241.
Health management coordinators
are available to accept authorization
requests during normal business hours
(Monday–Friday, 8 am to 5 pm).
• Authorizations can be sent to a secure,
confi dential fax machine in the
Health Management Department
at 207-253-6228.
• Requests may be submitted using
the Generations Advantage Request
for Authorization Form or using the
provider’s documentation (as long as
it includes required information).
HMO members’ requests for authorization relating to non-network providers must be submitted by the member’s PCP to Martin’s Point Generations Advantage. In-network services requiring authorization may be requested by the member’s PCP or by a provider/facility that the member has been referred to. If the request is made by a provider that the member has been referred to, that provider should send follow up notes and reports to the referring PCP.
• Unlisted CPT procedure codes
• Uvulectomy
• Uvulapalatopharyngoplasty
• Vision-correcting laser surgery
8
Authorization Process Components (cont.)
• Request for Authorization Forms
can be found on the Martin’s Point
Generations Advantage website at
martinspoint.org
• Authorization requests are processed by
CMS and URAC standards.
• Authorization determination letters are
sent to the member, “refer to” physician,
and facility (if applicable). If authorization
for the requested service is denied, the
reason for the denial is included in the
written notifi cation sent to the
member and provider. Upon request,
Generations Advantage will furnish the
criteria used to make the authorization
determination to the requesting provider.
• Denials based on medical necessity are
made only by physicians.
• Retroactive requests for authorization
will be accepted for up to 90 days from
original claim payment date or denial date.
• Authorization denials may be appealed.
• Providers may appeal an authorization
denial by contacting Martin’s Point
Provider Inquiry Department at
1-800-732-7364.
9
Web-Based Provider Resources
Resources are available online for
providers to access. Visit
martinspoint.org and click on
“For Network Providers” on the left
navigation bar. You will fi nd:
• The most recent Provider Directory
• Forms and documents (click on
“Provider Resources”)
• Member Handbook
• Additional information about
Generations Advantage
Medicare Learning Network
MLN Matters—there is an easy link to
the “Medicare Learning Network” site
from the martinspoint.org site. Go to
martinspoint.org, click the left navigation
bar for “For Network Providers”
and then click link for Medicare
Learning Network. This link brings
you to Medicare’s site for updates and
regulatory information.
Utilization Management
The Utilization Management Program
promotes quality cost-effective health care
by helping ensure that health care services
recommended or rendered are medically
necessary and appropriate. The Utilization
Management Program may include the
following components:
a) inpatient pre-admission certifi cation,
b) case management/inpatient
case management,
c) retrospective reviews,
d) maternity length of stay,
e) outpatient pre-certifi cation,
f) concurrent review, and
g) discharge planning.
Utilization management reviews can be
initiated by calling Martin’s Point
Health Management Department
at 1-888-339-7982.
Please note—Prior authorization and utilization management requirements vary. Please contact Generations Advantage to confi rm the requirements that apply to specifi c Generations Advantage members.
1010
Electronic Data Interchange with Martin’s Point Health Care
Martin’s Point is pleased to offer two
Electronic Data Interchange (EDI)
options so you can submit claims for
Generations Advantage members.
Relay Health, a division of McKesson Technologies
Contact Relay Health
at 1-866-735-2963 to
sign up. Current clients
of Relay Health should
call 800-527-8133.
For more information, please visit
www.relayhealth.com.
Payor ID: MPHC2
Offi ce Ally
Log on to www.offi ceally.com. From the
toolbar click on the “Register” tab, the
select the “Enroll Now” button (below
the mouse). From here, complete the
Enrollment Form. Or call 1-866-575-4120
option 3 to sign up.
Payor ID: MPHC1
If you are already
working with a vendor
for your electronic
claims, please contact
your vendor directly.
Questions?Call our
Provider Inquiry Department at
1-888-732-7364for more information.
11
Martin’s PointGenerations AdvantagePO Box 9746Portland, ME 04104-9882
Topic Contact Phone
Member Eligibility
Benefi t Information
Claims Status
Claims Payment
General Information
Provider Inquiry
Department
Phone: 1-888-732-7364
Fax: 207-253-6233
Prior Authorization
Discharge Planning
Medical Necessity Reviews
Sub-acute and Home Care
Health Management
Department
Phone: 1-888-339-7982
Fax: 207-253-6228
Provider Education
Provider Contract
Physician Changes
Closed Practices
Complex Issues
Network Management Phone: 1-800-348-9804
(option 4)
Phone: (207) 253-6930
(option 4)
Fax: (207) 828-7870
Pharmacy Questions/Coverage Caremark Eligibility: 1-866-544-
7504
Claims: 1-800-364-6331
Behavioral Health Systems Behavioral Health Care
Program (BHCP)
Phone: 1-888-708-4532
Transplant Services Health Management
Department
Phone: 1-888-339-7982
Fax: 207-253-6228