Fallon Health is a non-profit organization that holds contracts with the Centers for Medicare & Medicaid Services (CMS), the Massachusetts Medicaid program (MassHealth) and the New York Department of Health (NYDOH). In order to provide cost-effective, quality health care services and prescription drug coverage to our members enrolled in any of our government programs, Fallon Health contracts with external individuals and entities to support our plans and members.

• CMS categorizes these individuals and entities as First Tier, Downstream, and Related Entities (FDRs).
• MassHealth refers to similarly contracted entities as material subcontractors. 
• NYDOH refers to these contracted entities as providers.
• Collectively, Fallon Health refers to FDRs, Material Subcontractors and Providers as business partners or government program vendors. 

Our business partners and health care providers that support our Medicare and Medicaid plans are required to comply with the contractual requirements outlined in their agreements with Fallon Health, as well as applicable state or federal laws and regulations.

We’re committed to delivering quality care to our members with integrity, and we hold our business partners and health care providers to the same standard. Our compliance program helps all of us:

• Reduce and prevent fraud, waste, and abuse (FWA).
• Comply with applicable laws, rules, and regulations.
• Do the right thing. 

Compliance resources

• Business Partners and Health Care Providers Code of Conduct (pdf) (Update January 2024)
• Disciplinary Standards Policy (pdf) (Update January 2024)
• False Claims Act Policy (pdf) (updated July 2024)
• False Claims Act Policy Attachments (pdf) (updated July 2024)
• Routine Monitoring and Auditing Policy (pdf) (updated January 2024)
• Fraud, Waste and Abuse (FWA) Prevention and Detection Policy (pdf)  (updated January 2024)
• Uses and Disclosures of PHI Policy (pdf) (updated January 2024)
• Non-Retaliation Policy (pdf) (updated January 2024)
• Non-Employee Acceptable Use of Information Systems and Equipment (pdf) (updated January 2024)

First Tier, Downstream, and Related Entities