Physician & provider FAQ
To better serve our Fallon Health physicians and providers, we have compiled some of the most frequently asked questions below.
Don't see your question listed here? Let us know and we'll work on adding it to our list!
On this page:
Other FAQs:
How can I become a provider for Fallon Health?
Please fill out our letter of interest form. If you are a member of a PHO or IPA, please contact your PHO administrator or IPA president.
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How can I determine if a member is active and which Fallon Health product they have?
Contracted providers can log in to the provider portal to access member eligibility information.
You can also find out if a member is active by checking a member's Fallon Health ID card. All members receive an ID card when they enroll. This card should be photocopied for your office records. All Fallon Health ID cards will indicate the product the member has, such as Fallon Medicare Plus™, NaviCare®, Community Care, or one of our MassHealth ACO plans.
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Who should I contact if I have questions on my fee schedule?
If you belong to an IPA/PHO, please contact the administrator at your IPA/PHO.
Otherwise, you may contact the toll-free Provider Service Line at 1-866-275-3247, and request to speak with the Contracts Department. You will be directed to the contract manager who handles your contract.
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Do I need to bill with my NPI number?
Yes, it is very important that you submit your NPI number on your paper and electronic claims.
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Can I submit my claims electronically?
Yes, Fallon Health accepts claims electronically through one of two methods.
One method of sending claims to Fallon Health electronically is to use a clearinghouse. To send your claims via this method, your office will need to enroll with Fallon Health's contracted clearinghouse. Once enrolled, all you need to do is send your claims data through to the clearinghouse. The clearinghouse will then pass the file through standard data specifications and send it directly into our claims payment system.
You must be sure to notify the clearinghouse of your decision to submit claims to Fallon Health through their system before attempting to do so. You are required to provide your NPI number to the clearinghouse.
The second method for submitting claims to Fallon Health through the electronic data interchange (EDI) process is direct submission.
Fallon Health offers two secure options:
- VPN Client
- Secure file transfer over the web
To submit claims directly, your system must support ANSI X12 837 transactions and have FTP software installed.
To get started, register for the provider portal. Once your registration is confirmed, contact our EDI coordinators at 1-866-275-3247 (option 6) or email.
Fallon Health will review your enrollment form to determine which transmittal option best suits your needs.
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What specifications does Fallon Health require for electronic transactions?
Due to the regulations imposed by HIPAA (the Health Insurance Portability and Accountability Act), all formatting for electronic transmissions is in process of transitioning to ANSI ASC X12 837 specifications.
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What provider claims are accepted for electronic submission?
Answer:
The following providers may submit claims electronically:
- Primary care physicians
- Most specialists
- Radiology
- Laboratory
- Hospital
- Ambulance
- Anesthesia
Fallon Health currently does not accept electronic submissions from chiropractors or noncontracted providers.
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What if I have a question regarding a claim?
To speak with a representative about a member claim, call the toll-free Provider Service Line at 1-866-275-3247, and press 2.
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How do I appeal a claim?
If you do not agree with a determination made by Fallon Health, you may have the right to appeal.
All requests for appeals related to late submission, lack of medical necessity or preauthorization issues must be submitted within 120 days from the original date of the Remittance Advice Summary or initial denial.
All requests must be submitted in writing using the Request for Claim Review form and include all pertinent information to substantiate your request. The form and supporting information may be faxed to the provider appeals coordinator at 1-508-368-9890 or mailed to:
Fallon Health
Attn: Request for Claim Review/Provider Appeals
PO Box 211308
Eagan, MN 55121-2908
All appeal determinations will be final and binding in keeping with the provisions of your contract with Fallon Health or PHCS.
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How do I request an adjustment to a claim?
All requests for an adjustment must be made to the Fallon Health Claims Department within 120 days from the original date of the Remittance Advice Summary using the Request for Claim Review form. Any request for an adjustment received after 120 days will not be accepted. The form may be faxed to 1-508-368-9890, or mailed to:
Fallon Health
Claims Department: Adjustment Team
PO Box 211308
Eagan, MN 55121-2908
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What is the difference between an appeal of a claim and an adjustment of a claim?
An appeal of a claim relates to denials due to late submission, a lack of medical necessity or lack of preauthorization of a service. This type of appeal is reviewed by the Provider Appeals Team, and as needed, a medical director.
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