Authorization requirements, criteria, and policies

The following links are to the approval requirements and medical criteria for certain services and benefits. In most cases, your provider will take care of authorization of services. 

Behavioral health medical necessity criteria
Medical criteria for behavioral health services

Dental claim utilization and review criteria (pdf)
National standardized criteria to provide guidance for your clinical dental consultant

Diagnostic imaging services
Prior authorization requirements for high-tech outpatient diagnostic imaging, such as CT scans, PET scans, MRIs and Nuclear Cardiac Imaging

InterQual medical necessity criteria
Login to view the criteria Fallon Health uses to guide coverage determination decisions

Medical policies
Policies for medical treatments

Pharmacy prior authorization documentation
Covered prescription drugs that have prior authorization requirements

Sleep therapy
Prior authorization requirements for sleep therapy, sleep studies and related supplies