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.

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feel free to contact us at the numbers

provided on the inside back cover.

22222

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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.

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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.

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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

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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

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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.

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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.

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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.

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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

1-888-732-7364