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Mon., Tue., Thu., Fri.: 8 a.m. to 6 p.m. Wed: 10 a.m. to 6 p.m.

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A doctor treats her patient

Moving foward. Together.
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Related Links

  • Provider Manual
  • Contact us

Forms

The forms most frequently needed by Fallon Health providers are listed below.

Claims and appeals

  • Health Insurance Claim Form (pdf)
  • Request for Claim Review Form and Reference Guide (pdf)
  • Third Party Liability Indicator Form (pdf)
  • Waiver of Liability Statement (pdf)

Doing business with Fallon Health

  • Material Request Form
  • OB/GYN Provider Attestation Form - Fallon ACO plans only (pdf)
  • ProAuth Enrollment Request Form (pdf)
  • Register for Provider Tools and electronic data submission
  • Update your practice information
  • Standardized Provider Update Form (pdf) 

Forms for your patients (our members)

  • PCP selection/change form (pdf)

Pharmacy

  • Pharmacy Prior Authorization Forms
  • Special Formula Medical Necessity Form (pdf)

Referrals and authorizations

  • Case Management Referral Form (pdf)
  • Disease Management Referral Form  (pdf)
  • Infertility Services Prior Authorization Request Form (pdf)
  • MCE Behavioral Health Provider/Primary Care Provider Communication Form (pdf)
  • ProAuth Enrollment Request Form (pdf)
  • Safe Transitions Referral Form (pdf)
  • Skilled Nursing Facility Admission Review Request (pdf)
  • Skilled Nursing Facility Request for Continued Stay Form (pdf)
  • Standardized Prior Authorization Request Form (for non-pharmacy PAs)
  • Universal Health Plan/Home Health Authorization Form (pdf) 
     

    Is there an additional form or two you would like listed here? Let us know!

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Provider Tools

Log in

Registration for first time users
Need help? AskFCHP@fallonhealth.org

Quick links for providers

  • Eligibility verification
  • Claims metrics
  • Pharmacy prior authorization
  • Medical policies
  • Forms
  • Update your information

Quick links

  • Find insurance
  • Members
  • Employers
  • Providers
  • Brokers
  • Compliance/Business Partners

Helpful tools

  • Find a doctor
  • MyFallon member portal
  • Online drug formulary
  • Find a pharmacy
  • Healthwise Knowledgebase
  • Provider Tools

Our plans and products

  • Community Care
  • Fallon Medicare Plus - Plan Year 2025
  • NaviCare
  • Summit ElderCare (PACE)
  • MassHealth (Medicaid)

Developer resources

  • Transparency in Coverage MRFs
  • Provider directory API - Practitioner
  • Provider directory API - Organization
  • Provider directory API - Location
  • Provider directory API - Insurance plan
  • Provider directory API - Practitioner role

© 2025, Fallon Health. All rights reserved. | Privacy and confidentiality notice | HIPAA Notice of Privacy Practices

1 Mercantile St., Ste. 400, Worcester, MA 01608
1-800-868-5200 (TRS 711), Mon., Tue., Thu., Fri.: 8 a.m. to 6 p.m. Wed: 10 a.m. to 6 p.m.

Notice of inclusion resources (pdf)

 

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Anonymous Compliance Hotline: Call our Compliance Hotline to report any concerns you may have regarding compliance, fraud, waste or abuse. You can call the Hotline 24 hours a day, seven days a week. All calls are anonymous and confidential.

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