Physician & provider FAQ

To better serve our Fallon 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!
Note: There may be different answers for our PPO product, Fallon Preferred Care.

On this page:

Question:
How can I become a provider for Fallon Health?

Answer:
If you are an independent provider office, you should fax a letter of intent on your letterhead to our Network Development and Contracting Department at 508-752-6878 or email askfchp@fchp.org.  Please include the name of the group, names of providers in the group, and any specialties provided in the office. 

If you are a member of a PHO or IPA, please contact your PHO administrator or IPA president.

If you are a chiropractor and are interested in joining, please contact American Specialty Health at 800-848-3555.

| Back to top |


Question:
How do I update the mailing or site address of a provider’s office?

Answer:
To update any information (i.e. phone and fax numbers, site address, billing address), please fax the updated information on letterhead to 1-508-368-9902 or email askfchp@fchp.org.  If there is a change to the billing address, please also fax an updated W-9.

| Back to top |


Question:

How can I determine if a member is active and which Fallon product they have?

Answer:
Confirming eligibility is easy by using Provider Tools. From the Physicians and providers home page, click on Eligibility verification to access member eligibility information. If you have not registered for access, click on Provider Tools for more information on what options are available to you with this tool. Then, click Register today to download a registration packet.

You can also find out if a member is active by checking a member's Fallon ID card. All members receive an ID card when they enroll. This card should be photocopied for your office records. All Fallon ID cards will indicate the product the member has, such as FCHP Select Care, FCHP Direct Care, FCHP Flex Care Select, FCHP Flex Care Direct, Fallon Senior Plan,™ Fallon Preferred Care or Major Medical.

| Back to top |


Question:
Who should I contact if I have questions on my fee schedule?

Answer:
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.

For contract questions related to Fallon Preferred Care, contact Private Healthcare Systems (PHCS) at 1-866-416-6489. Reliant Medical Group (formerly Fallon Clinic) providers should contact the Fallon Provider Service Line at 1-866-275-3247.

| Back to top |


Question:
Do I need to bill with my NPI number?

Answer:
Yes, it is very important that you submit your NPI number on your paper and electronic claims.

| Back to top |


Question:
What form do I use to submit my referrals?

Answer:
Please see "How do I submit referrals" below. 

| Back to top |


Question:
How do I submit referrals?

Answer:
The PCP refers the member to a specialist within the member’s product for medically necessary care. The PCP contacts the specialist by telephone, fax or mail, and provides their name, the NPI number, the reason for the referral and number of visits approved.  After the specialist verifies the member’s eligibility, the specialist treats the member according to the PCP’s request and exchanges clinical information with the member’s PCP. The specialist submits a claim to Fallon with evidence of a referral (i.e., the NPI number) from the member’s PCP.  

For specific billing instructions, refer to the Billing procedures section of the Provider Manual. 

PCP referrals will be accepted retroactively up to 120 days from the date of service. Should an initial claim be rejected for lack of a referral number (i.e., the NPI number), the specialist has 120 days from the date of the RAS to resubmit a corrected claim with the NPI number. Please note that all corrected claims must be dropped to paper and marked “corrected claim.” Corrected claims cannot be submitted electronically. In addition, providers may call 1-866-ASK-FCHP, press 1, and Fallon will accept the NPI number via telephone within the 120-day period. A corrected claim won’t be mandatory.

For more information on the referral process, refer to the Provider Manual.

Fallon Preferred Care members
For Fallon Preferred Care members, no referrals are required, but the following covered services do require precertification or plan notification:

  • All nonemergency inpatient admissions
  • Same-day surgery
  • Durable medical equipment and prosthetic/orthotic devices
  • Home health care services
  • Hospice care
  • Infertility services
  • Nonemergency ambulance transport (Note: Routine transportation to and from medical care providers is not covered.)

| Back to top |


Question:

In the past, Fallon always required preauthorization for elective same-day surgery. Has the procedure changed?

Answer:
Fallon has implemented changes in the referral process, including elective hospital/facility same-day surgery and ambulatory procedures. For all products, it is the responsibility of the facility to notify the plan of all elective hospital/facility same-day surgery and ambulatory procedures that are on the list identified in the Provider Manual. In addition, the services identified on the list in the Provider Manual also require plan preauthorization.

For Fallon Preferred Care members, same-day surgery requires precertification. Private Healthcare Systems (PHCS) handles precertification for the Fallon Preferred Care product and can be reached at 1-866-416-6489.

| Back to top |


Question:
Can I submit my claims electronically?

Answer:
Yes, FCHP accepts claims electronically through one of two methods.

One method of sending claims to Fallon electronically is to use a clearinghouse. To send your claims via this method, your office will need to enroll with one of Fallon's contracted clearinghouses. Once enrolled, all you need to do is send your claims data through to the chosen 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 a clearinghouse of your decision to submit claims to Fallon through their system before attempting to do so. You are required to provide your NPI number to the clearinghouse.

Fallon currently contracts with the following clearinghouses:

The second method for submitting claims to FCHP via the electronic data interchange (EDI) process is to send them direct. Call 1-866-ASK-FCHP, ext. 69968, or email our EDI coordinators who will be happy to assist you.

Direct submission requires that your system be able to send transactions in the ANSI X12 837 Version 4010, and that you have FTP software. There are three transmittal options: VPN Lan-Lan, VPN Client, or secure file transfer over the Web. FCHP will review your enrollment form to determine which transmittal option best suits your needs. For more information, see Electronic data submission.

| Back to top |


Question:
What specifications does Fallon require for electronic transactions?

Answer:
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, Version 4010.

| Back to top |


Question:
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 currently does not accept electronic submissions from chiropractors or noncontracted providers.

| Back to top |


Question:
How do I bill when I am a covering physician?

Answer:
If you are covering for another physician and submitting on paper claims, the words "Covering Physician" must be typed directly on the claim. If submitting electronically, the words "Covering Physician" must appear in the comments section of the claim.

| Back to top |


Question:
What if I have a question regarding a claim?

Answer:
To speak with a representative about a member claim, call the toll-free Provider Service Line at 1-866-275-3247, and press 2.

| Back to top |


Question:
How do I appeal a claim?

Answer:
If you do not agree with a determination made by Fallon, 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
P.O. Box 15121
Worcester, MA 01615-0121

All appeal determinations will be final and binding in keeping with the provisions of your contract with Fallon or PHCS.

| Back to top |


Question:
How do I request an adjustment to a claim?

Answer:
All requests for an adjustment must be made to the Fallon 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
P.O. Box 15121
Worcester, MA 01615-0121

For Fallon Preferred Care Claims, please mail the Request for Claim Review form to:

Fallon Preferred Care
P.O. Box 15207
Worcester, MA 01615-0207

| Back to top |


Question:
What is the difference between an appeal of a claim and an adjustment of a claim?

Answer:
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.

| Back to top |