News and announcements
July 2023 Connection newsletter
- Return to referral requirements
Update: Upon further review of the MassHealth All provider Bulletin 371, Fallon Health will be consistent with the CMS regulation of requiring a PCP referral requirement for Navicare members effective 7/1/23. Note there is a retro referral period to enter post service PCP referrals of 90 days from the date of service.
As communicated previously: For our MassHealth ACO plans—Berkshire Fallon Health Collaborative, Fallon 365 Care, and Fallon Health-Atrius Health Care Collaborative— the PCP referral suspension will continue through December 31, 2023. PCP referrals are required for Fallon Medicare Plus, Fallon Medicare Plus Central, Fallon Medicare Plus Premier HMO, and Fallon Medicare Plus Premier HMO Central effective July 1, 2023, and continue to be required for Community Care.
- MassHealth ACO reimbursement
- MassHealth ACO prior authorization requirements for formula
- E-consults: Supporting PCPs and expanding access
- Update on specialty drug access
- Preferred product changes under the Medical Benefit
- MassHealth ACO Unified Formulary Opioid and
- Pain Initiative
- MassHealth ACO full uniform formulary changes
Read past issues of Connection
Community Care Qualifying Payment Amount (QPA) for Non-contracted Providers
New federal and state requirements concerning surprise billing have taken effect. Fallon Health recently began paying out-of-network claims for the Community Care product pursuant to the federal No Surprises Act. The allowed amount for out-of-network claims covered by the No Surprises Act will be set at the Qualifying Payment Amount (QPA).
- Fallon Health is working with our vendor partner ClearHealth to identify claims subject to the No Surprises Act and to determine the appropriate QPA.
- For any claims paid in accordance with the No Surprises Act, the Fallon Remittance Advise (RAS) will note at a claim line level “Paid according to the qualifying payment amount (QPA), as defined by the No Surprises Act Regulations.” A Provider Adjustments and Appeals letter with additional details will be included with the RAS.
- If an out-of-network provider or facility wishes to initiate a 30-day open negotiation period for purposes of determining the amount of final payment to the provider or facility, they may contact ClearHealth via the secure portal https://provider.clearhs.com or by calling (866) 722- 3773.
Paper claims P.O. Box issues
When shipping paper claims that are not deliverable to a P.O. Box, (via FedEx etc.), please send to the following address:
Fallon Health Claims- Smart Data Solutions
960 Blue Gentian Road
Eagan, MN 55121
Opioid management program and pain management alternatives
Pharmacy updates
MassHealth.
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