News and announcements

April 2024 Connection newsletter

  • Expanded support for hospitals to meet the needs of behavioral health members
  • Obesity drugs and 340B drug pricing program
  • New Pharmacy Step Therapy exception request process
  • NaviCare® Model of Care training
  • NaviCare Model of Care success
  • Provider notification of DOI Bulletin 2024-02
  • And more

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 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


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