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Secure
Register for Provider Tools and EDI

Register for Provider Tools and electronic data submission

If you would like secure access to Fallon Health’s Provider Tools, please have your office manager fill out the form below. Upon receipt and review by Fallon, your assigned username and password will be forwarded to each authorized individual. If you do not hear back from us within 15 business days, please call 1-866-275-3247, option 6, fax us at 1-508-368-9996 to confirm receipt or email us at edi.coordinator@fallonhealth.org.

Provider information

Vendor/provider/facility name:

Group NPI #: (required)

Provider mailing address (line 1):

Provider mailing address (line 2):

State:

City:

ZIP:

Telephone number:

Please enter the phone number in the following format: 123-123-1234.

Fax number:

Please enter the fax number in the following format: 123-123-1234.

Vendor contact name:

Vendor contact email address:

Vendor phone number:

Please enter the phone number in the following format: 123-123-1234.

Are you a new or existing provider tools user? New Existing

Provider tools user authorization

Below, please list the employees to be granted access to Provider Tools through fallonhealth.org. To request access to Provider Tools for third-party agencies, complete the Billing Agency Authorization Form in addition to this form.

Employee 1 first name:

Employee 1 middle name:

Employee 1 last name:

Employee 1 email address:

Provider tool access for employee 1: PCP panel reports - PCPs only Provider referral monitoring report - PCPs only Claims metric reports - contracted providers only Eligibility verification

Please indicate the type of access you are requesting by checking the corresponding box.

Employee 2 first name:

Employee 2 middle name:

Employee 2 last name:

Employee 2 email address:

Provider tool access for employee 2: PCP panel reports - PCPs only Provider referral monitoring report - PCPs only Claims metric reports - contracted providers only Eligibility verification

Employee 3 first name:

Employee 3 middle name:

Employee 3 last name:

Employee 3 email address:

Provider tool access for employee 3: PCP panel reports - PCPs only Provider referral monitoring report - PCPs only Claims metric reports - contracted providers only Eligibility verification

Employee 4 first name:

Employee 4 middle name:

Employee 4 last name:

Employee 4 email address:

Provider tool access for employee 4: PCP panel reports - PCPs only Provider referral monitoring report - PCPs only Claims metric reports - contracted providers only Eligibility verification

Employee 5 first name:

Employee 5 middle name:

Employee 5 last name:

Employee 5 email address:

Provider tool access for employee 5: PCP panel reports PCPs only Provider referral monitoring report PCPs only Claims metric reports contracted providers only Eligibility verification

Employee 6 first name:

Employee 6 middle name:

Employee 6 last name:

Employee 6 email address:

Provider tool access for employee 6: PCP panel reports PCPs only Provider referral monitoring report PCPs only Claims metric reports contracted providers only Eligibility verification

Employee 7 first name:

Employee 7 middle name:

Employee 7 last name:

Employee 7 email address:

Provider tool access for employee 7: PCP panel reports PCPs only Provider referral monitoring report PCPs only Claims metric reports contracted providers only Eligibility verification

Employee 8 first name:

Employee 8 middle name:

Employee 8 last name:

Employee 8 email address:

Provider tool access for employee 8: PCP panel reports PCPs only Provider referral monitoring report PCPs only Claims metric reports contracted providers only Eligibility verification

Employee 9 first name:

Employee 9 middle name:

Employee 9 last name:

Employee 9 email address:

Provider tool access for employee 9: PCP panel reports PCPs only Provider referral monitoring report PCPs only Claims metric reports contracted providers only Eligibility verification

Employee 10 first name:

Employee 10 middle name:

Employee 10 last name:

Employee 10 email address:

Provider tool access for employee 10: PCP panel reports PCPs only Provider referral monitoring report PCPs only Claims metric reports contracted providers only Eligibility verification

Access to PCP panel reports and referral monitoring report

If you would like multiple providers to have access to the authorization lookup tool, PCP panel reports and referral monitoring report, please fill out the information below. List the name and NPI number of provider in the office/group.

First name:

Last name:

NPI #:

If HCO, list HCO name: